Childhood Obesity Prevention: International Research, Controversies, and Interventions 9780199572915

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Childhood Obesity Prevention International Research, Controversies, and Interventions Edited by

Jennifer A. O'Dea Michael Eriksen

OXFORD UNIVERSITY PRESS

OXFORD UN I VERSITY P RESS

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Contents

List of Contributors xm

Section 1 Controversial issues in childhood obesity prevention High body mass index, overweight, a nd obesity in children: Definitions, terminology, and interpretation 3 Katherine M. Flegal and Cyn thia L. Ogden 2 Stigma and BM! screening in schools, or 'Mom, I hate it when they weigh me' 17 Lynne M. Maclean, Mechthild Meyer, Audrey Walsh, Kathryn Clin ton, L isa Ashley, Stephanie Donovan, and Nancy Edwards 3 Developing positive approaches to nutrition education and the preventi on of child and adolescent obesity: First, do no harm 3 / Jennifer A. O'Dea 4 Low family income and the overweight status of Canadian adolescents 42 Peter Burton and Shelley Phipps 5 Issues of teacher training in the prevention of eating disorders and childhood obesity in schools 56 Zali Yager

Section 2 Prevalence and factors associated with childhood obesity 6 Childhood overweight and obesity in developed countries: Global trends and co rrelates 69 Tim Olds and Carol Maher 7 A review of prevalence and trends in chil dhood obesity in the United States 84 Cynthia L. Ogden, Margaret D. Carroll, and Katherine M. Flegal 8 Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchil dren in studies from 2000 and 2006 95 Jennifer A. O'Dea and Michael J. Dibley 9 Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006 104 Zhaohui Cui and Michael J. Dibley 10 Trends in Hong Kong and Macao and other Chinese communities 117 Albert Lee 11 Overweight, obesity, and associated facto rs among Vietnamese and Southeast Asian children an d adolescents 132 Nguyen Hoang H. Doan Trang, Tang K. Hong, and Michael J. Dibley 12 Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03 144 Wolney Lisboa Cond e and Carlos Augusto Monteiro

x

I

CONTENTS

13 Trends in obesity and hypertension in South African youth 152

K. D. Monyeki, H. C. G. Kemper, and f. W.R. Twisk 14 Childhood obesity- recent trends in Sweden incl uding

socioecon omic differences 164 Elinor Sundblom, Agneta Sjoberg, Jennie Blank, and Lauren Lissner 15 Childhood obesity in the Middle Eastern countries with

special referen ce to Iran Roya Kelishadi

174

16 Trends in Israel 187

foav Merrick, Efrat Merrick-Kenig, and Mohammed Morad

Section 3 Approaches to prevention 17 Childhood obesity: Treatm ent or prevention? 195 Lawrence D. Hamm er 18 Relevant health educatio n and health promotion theory for

childhood obesity prevention 203 Karen Glanz and Brian E. Saelens 19 The application of public health lessons to childhood obesity prevention 213

Michael Eriksen, Rodney Lyn, and Barbara f. Moore 20 Towards a children's food and nutritio n policy 229

Anthony Worsley 21 Prevention and ma nagement of obesity in children and adolescents-the

Singapore experience 240 Ting Pei H o 22 Asian adolescents in New Zealand- a health promotion a pproach 250 Shirin Forough ian 23 The role of health professionals 258 Kelley De Vane Hart and Bonnie A. Spear

Section 4 Interventions 24 Striving to prevent obesity and other weight- related problems in adolescent girls: The New Moves approach 269

Dianne Neumark-Szta iner, Colleen Flattum, Sh ira Feldman, and Christine Petrich 25 Whole-school and health promoting school approaches to obesity

prevention-government policy directions in Australia between 2000 and 20 10 Jennifer A. O 'Dea 26 Interventions targeting childh ood obesity involving parents 300

Nancy Espinoza, Guadalupe X. Ayala, and Elva M . Arredondo 27 Promoting optimal weights in Aboriginal children in Canada through ecological research 309

Ashlee-Ann E. Pigford and Noreen D. Willows

278

CO NTENTS

28 Environment and policy interventions to prevent obesity in children 32 J

Dianne S. Ward, Amy V. Ries, and Rachel Tabak 29 lnd ividual and environmental interventions to prevent obesity in African American children and adolescents 333

Portia Jackson, Jammie Hopkins, and Toni Yancey 30 Targeted approaches by culturally appro priate programmes 348

Shiriki Kumanyika 31 Weight- related teasing and anti-teasing initiatives in schools 363

Jess Haines 32 Physical activity programmes in high schools 380

Fiona Brooks and Josephine Magnusson 33 Effective school meal interven tions: Lessons learned from Eat Well

Do Well in Hull, England 389

Derek Colquhoun and Jo Pike 34 Obesity preventio n interventions fo r early childh ood: An updated systemati c

review of the literature 396

Kylie Hesketh and Karen Campbell 35 Problems and possible solutions for interventions am on g children and adolescents 408

Tom Baranowski, Janice Baranowski, Karen Cullen, Melanie Hingle, Sheryl Hughes, Russell Jago, Tracey Ledoux, Jason Mendoza, Tuan T. Nguyen, Teresia O'Connor, Deborah Thompson, and Kathleen Watson Index 423

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List of Contributors

Elva M. Arredondo San Diego State University, USA

Michael J. Dibley University of Sydney, Australia

Lisa Ashley Canadian Nurses Association, and University of Ottawa, Canada

Stephanie Donovan University of Ottawa, Canada

Guadalupe X. Ayala San Diego State University, USA Janice Baranowski Baylor College of Medicine, USA Tom Baranowski Baylor College of Medicine, USA Jennie Blank University of Gothenburg, Sweden Fiona Brooks University of Hertfordshire, UK

Nancy Edwards University of Ottawa, Canada Michael Eriksen Georgia State University, USA Nancy Espinoza San Diego State University, USA Shira Feldman University of Minnesota, USA Colleen Flattum University of Minnesota, USA

Peter Burton Dalhousie University, Canada

Katherine M. Flegal National Center for Health Statistics, Centers for Disease Control and Prevention, USA

Karen Campbell Deakin University, Australia

Shirin Foroughian U niversity of Auckland, New Zealand

Margaret D. Carroll National Center for Health Statistics, Centers for Disease Co ntrol and Prevention, USA

Karen Glanz University of Pennsylvania, USA

Kathryn Clinton University of Ottawa, Canada Derek Colquhoun University of Hull, UK W olney Lisboa Conde University of Sao Paulo, Brazil Zhaohui Cui University of Syd ney, Australia Karen Cullen Baylor College of Medicine, USA Kelley DeVane Hart University of Alabama at Birmingham, USA

Jess Haines Harvard Medical School/Harvard Pilgrim Health Care Institute, USA Lawrence D. Hammer Stanfo rd University, USA Kylie Hesketh Deakin University, Australia Melanie Hingle Baylor College of Medicine, USA TingFei Ho Gleneagles Hospital, Singapore TangK. Hong Pham Ngoc T hach University of Medicine, Vietnam

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LIST OF CONTRIBUTORS

Jammie Hopkins University of California, Los Angeles, USA Sheryl Hughes Baylor College of Medicine, USA Portia Jackson University of California, Los Angeles, USA Russell Jago Baylor College of Medicine, USA Roya Kelishadi Isfahan University of Medical Sciences, Iran H.C.G. Kemper VU University Medical Center, The Netherlands Shiriki Kumanyika University of Pennsylvania School of Medicine, USA Tracey Ledoux Baylor College of Medicine, USA

Efrat Merrick-Kenig National Institute of Child Health and Human Development, Ministry of Social Affairs, Israel Mechthild Meyer Gentium Consulting a nd University of Ottawa, Canada Carlos Augusto Monteiro University of Sao Paulo, Brazil K.D. Monyeki Medical Research Council, South Africa Barbara J. Moore Shape Up America!, USA Mohammed Morad National Institute of Child Health and Human Development, Ministry of Social Affairs, Israel Dianne Neumark-Sztainer University of Minnesota, USA Tuan T. Nguyen Baylor College of Medicine, USA

Albert Lee The Chinese University of Hong Kong, Hong Kong

Teresia O'Connor Baylor College of Medicine, USA

Lauren Lissner University of Go thenburg, Sweden

Jennifer A. O 'Dea University of Sydney, Australia

Rodney Lyn Georgia State University, USA

Cynthia L. Ogden National Center for Health Statistics, Centers for Disease Co ntrol and Prevention, USA

Lynne M. Maclean University of Ottawa, Canada Josephine Magnusson University of Hertfordshire, UK Carol Maher University of South Australia, Australia Jason Mendoza Baylor College of Medicine, USA Joav Merrick National Institute of Child Health and Human Development, Ministry of Social Affairs, Israel

Tim Olds University of South Australia, Australia Christine Petrich University of Minnesota, USA Shelley Phipps Dalhousie University, Canada Ashlee-Ann E. Pigford University of Alberta, Canada

LIST O F CO NTRIBUTORS

Jo Pike UniversityofHull, UK AmyV. Ries University of North Carolina, Chapel Hill, USA

Brian E. Saelens Seattle Children's H ospital Research Institute, and the U niversity of Washington, USA Agneta Sjoberg University of Gothenburg, Sweden Bonnie A. Spear University of Alabama at Birmingham, USA Elinor Sundblom Karolinska Institute, Sweden Rachel Tabak University of North Carolina, Chapel Hill, USA Deborah Thompson Baylor College of Medi cine, USA Nguyen Hoang H. Doan Trang Pham Ngoc T hach University of Medicine, Vietnam

J.W.R. Twisk VU University Medical Centre, The Netherlands Audrey Walsh Cape Breton University, Canada Dianne S. Ward University of North Carolina, Chapel Hill, USA Kathleen Watson Baylor College of Medicine, USA Noreen D. Willows University of Alberta, Canada Anthony Worsley U niversity of Wollo ngo ng, Australia Zali Yager La T robe University, Australia Toni (Antronette K.) Yancey University of Califo rnia, Los Angeles, USA

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(p.v) Foreword

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

(p.v) Foreword The implications of the social determinants of health are that actions to improve the public health must include actions outside the health sector. Listening to me expound this, one British Minister of Health, seeking justification of his public health role, happened on obesity. Surely, he argued, there is much that the health sector can do about obesity. Obesity was not the best example he could have chosen. Certainly, the consequences of obesity have huge implications for the health care sector worldwide. It is the causes of obesity that require action elsewhere. The Commission on Social Determinants of Health (CSDH), convened by the WHO, adopted the language of ‘the causes of the causes’. We know that obesity is caused by caloric imbalance – too much energy intake for too little output – but it is the causes of these causes that require unravelling and, once unravelled, action to address them. The ‘causes of the causes’ is very much the perspective taken by this impressive new international volume. A second theme of the Commission on Social Determinants of Health is also emphasized here: equity from the start. The CSDH was impressed by the research showing the importance of what happens in childhood and adolescence for health and health inequity in adult life. This volume’s focus on obesity in young people proceeds from an assumption that a good time to address the causes of the obesity epidemic is early in life. Certainly figures for obesity in adolescents such as those produced here are quite alarming. In the USA, for example, 15% of adolescent girls and boys have a high Body Mass Index. If these young people are destined to lives of obesity their futures will be marked by increased risk of diabetes, vascular disease, and cancer. The social distribution of obesity is important for reasons both of scientific understanding and social significance. Particularly in girls, perhaps somewhat less in boys, obesity follows a social gradient: the lower the social position the higher the levels. The fact that these are reproducible social patterns in developed countries worldwide means that the search for explanations must go beyond the individual as must the search for solutions to prevention of obesity. The fact that obesity is increasing among more well-off children in developing countries such as China and Vietnam raises issues about potentially adverse and unintended outcomes of rapid economic

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(p.v) Foreword

development. The social significance, picking up a core concern of the CSDH, is that social inequalities in health, that are judged to be avoidable, are unfair. Putting them right is a matter of social justice. The message of social justice should be separated from labelling of individuals. That avoidable health inequalities – health inequity – should be tolerated is wrong and requires social action. This does not translate into personal morality. Screening children and labelling them as obese or overweight could easily acquire moral overtones, that they are somehow bad people for being overweight. This is neither fair nor useful, and should be avoided. A social perspective on obesity and its prevention is consistent with the evidence, and it is the evidence that really matters when it comes to planning interventions. Chapters in this volume give pause. One reads them with knowledge reinforced of the social determinants of obesity; one cannot read them and come away secure in the knowledge that we know what to do. Some chapters are more cautious than others, but taken as a whole they do not give grounds for relying on education, aimed at individual young people, as a solution to this health problem. Social and environmental interventions appear to hold more promise, but even here the evidence leaves the authors with varying degrees of caution. Evaluation of efforts is a key part of taking the agenda forward. (p.vi) The editors and authors are to be congratulated for bringing together a definitive range of reports on child and adolescent obesity. They highlight a most important health issue that contributes importantly to health inequity and bring us up to date with the state of knowledge of what can be done. A most impressive achievement. Professor Sir Michael Marmot MBBS, MPH, PhD, FRCP, FFPHM, FMedSci, Director of the International Institute for Society and Health, MRC Research Professor of Epidemiology and Public Health, University College, London

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(p.vii) Preface

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

(p.vii) Preface In this new book we have brought together some of the world’s most highly regarded researchers, health and education practitioners, and theorists to combine several facets of health education theory, research, and practice to guide the prevention of childhood obesity and the promotion of child and adolescent health and well-being. Controversial issues in the prevention of childhood obesity need to be considered early in the development of school, clinical, or community prevention programmes, as these issues are often the ones that promote the success or failure of attempts to ameliorate the problem at hand. In the first section of this book, the controversial issues covered include whether or not schools should become involved in the measurement of students’ weight for height; how researchers can properly measure and interpret such data while taking into account its many limitations; what to do (or not to do) with any data collected; how best to involve school staff and teachers and whether to combine childhood obesity prevention within a broader framework and spectrum of prevention of ‘weight and eating issues’ such as eating disorders, dieting, and disordered eating. Finally, this section highlights the relationship between obesity and poverty, and the authors make suggestions for how to understand and approach both problems. These are all controversial, yet vital issues for anyone planning a childhood obesity prevention programme and we are fortunate to have such world class leaders in the field to share their experience and evidence-based perceptions. Section 2 includes several chapters that report on current prevalence from various countries, including a very thorough review of childhood obesity prevalence trends worldwide. The chapters in this section suggest a plateauing of childhood obesity in Western Europe, Canada, Scandinavia, the USA, and Australia, but a continuing rise in Asian countries, South Africa, South America, and the Middle East. The reasons for these trends and how to implement the most appropriate and suitable preventive initiatives are discussed. Section 3 deals with some varied approaches to the prevention of childhood obesity with comments from some highly experienced and world renowned expert researchers. Important

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(p.vii) Preface

debates and consideration of issues include how to combine clinical treatment with preventive approaches; include health professionals; engage and empower community members; understand how health education and health promotion theory can be utilized to plan the design of interventions; and how to decide which public health lessons can be best utilized to approach childhood obesity prevention. The comparisons of childhood obesity prevention with lessons learned from the public health prevention of tobacco use are clearly outlined and debated. The chapter documenting the obesity prevention project previously conducted in Singaporean schools clearly illustrates how to avoid adverse and unexpected outcomes such as opposition from parents and the creation of food concerns, body image problems, and eating disorders. Finally, Section 4 presents a broad range of approaches for interventions including several overviews of the various interventions to date; suitable school-based prevention approaches; interventions involving parents; physical activity interventions; and importantly, how to effectively design and implement the most culturally appropriate childhood obesity interventions. (p.viii) Many thanks to the long list of highly prestigious authors who generously gave their time and extensive expertise to contribute to the production of this important and timely book. Jennifer A. O’Dea and Michael Eriksen Sydney, Australia, July 2010

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High body mass index, overweight, and obesity in children: Definitions, terminology, and interpretation

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

High body mass index, overweight, and obesity in children: Definitions, terminology, and interpretation Katherine M. Flegal Cynthia L. Ogden

DOI:10.1093/acprof:oso/9780199572915.003.0001

Abstract and Keywords Studies in a variety of countries have shown increases in the prevalence of overweight and obesity among children in recent years. These increases have given rise to concern about children's health and well-being. The terminology used in these studies varies considerably. However, whatever the terminology used, such studies are generally based on weight (expressed as body mass index (BMI), a measure of weight for height, calculated as weight in kilograms divided by the square of height in meters) and not on body fatness per se. There are many different BMI references that can be used to define childhood overweight or obesity for population surveillance purposes using a variety of BMI cut-points. BMI is a screening tool, not a diagnostic tool. Children with a BMI over these cut-points do not necessarily have clinical complications or health risks related to over-fatness. More in-depth assessment of individual children is required to ascertain health status. The definitions based on BMI generally used are working definitions that are valuable for general public health surveillance, screening, and similar purposes. Terminology and measures used in studies of weight and adiposity in children and in adults is a complex area. Considerable confusion arises from the disparate uses of the descriptive terms ‘overweight’ and ‘obesity’ in children. Different reports may use the same term but define it quite differently. This chapter examines some of the definitions and terminology in use today and some of the underlying issues in arriving at consistent and coherent definitions.

Keywords: body mass index, BMI, overweight, obesity, children, diagnosis, measurement, interpretation

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High body mass index, overweight, and obesity in children: Definitions, terminology, and interpretation

Chapter summary Studies in a variety of countries have shown increases in the prevalence of overweight and obesity among children in recent years. These increases have given rise to concern about children’s health and well-being. The terminology used in these studies varies considerably. However, whatever the terminology used, such studies are generally based on weight (expressed as body mass index (BMI), a measure of weight for height, calculated as weight in kilograms divided by the square of height in meters) and not on body fatness per se. There are many different BMI references that can be used to define childhood overweight or obesity for population surveillance purposes using a variety of BMI cut-points. BMI is a screening tool, not a diagnostic tool. Children with a BMI over these cut-points do not necessarily have clinical complications or health risks related to over-fatness. More in-depth assessment of individual children is required to ascertain health status. The definitions based on BMI generally used are working definitions that are valuable for general public health surveillance, screening, and similar purposes.

Introduction Terminology and measures used in studies of weight and adiposity in children and in adults is a complex area. Considerable confusion arises from the disparate uses of the descriptive terms ‘overweight’ and ‘obesity’ in children. Different reports may use the same term but define it quite differently. In this chapter, we examine some of the definitions and terminology in use today and some of the underlying issues in arriving at consistent and coherent definitions. Strictly speaking, obesity refers to excess body fatness and overweight to weight in excess of a weight standard. In practice, measurement of body fat is difficult both in clinical applications and in population studies. In addition, there are no well-accepted standards for body fatness for children (or for adults) (WHO Expert Committee on Physical Status: The Use and Interpretation of Anthropometry, 1995). As a result, although many discussions revolve around the effects of excess fat, a measure of weight rather than fatness is almost always used. The most common metric in use today is body mass index (BMI), weight in kilogram divided by the square of height in meters. This index was originally devised by the Belgian statistician Adolphe Quetelet (1796–1874), who applied it to adults, not to children (Weigley, 2000). For adults, the index describes the relation of weight to height, in effect adjusting weight for height. It was subsequently shown for adults that if adiposity was independent of height, then BMI would be highly correlated with (p.4) adiposity (Benn, 1971; Keys et al., 1972; Khosla & Lowe, 1967). For adults, BMI provides a way to translate weights at different heights into a common metric. The use of BMI for children is a more recent development (Cole, 1979; Dietz & Robinson, 1998; Neovius et al., 2004). For children, BMI varies with age. Because of this, for children, BMI values are compared to reference values that are generally age- and usually also sex-specific and need to be further transformed in order to be put on a common footing. This is most often done by translating BMI-for-age into a z-score or a percentile relative to some specified distribution of BMI-for-age. Generally some smoothing process is applied to an empirical BMI distribution to generate smooth percentiles, and because BMI distributions are not infrequently

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High body mass index, overweight, and obesity in children: Definitions, terminology, and interpretation

skewed, a normalizing transformation is also applied, often as part of the smoothing process itself (Cole, 1990). A normalizing transformation allows for flexible calculation of z-scores. A z-score or standard deviation score represents the number of standard deviation units above or below the mean, so that, for example a z-score of 2 refers to a value that is two standard deviations above the mean. To calculate a z-score value, a normal transformation of the distribution of BMI for that age and sex group is applied and the z-score is calculated relative to the mean and standard deviation of the normalized BMI distribution. Z-scores and percentiles have a 1 to 1 equivalence in a normal distribution; any percentile can be translated to a z-score and vice versa. At a given age, a specified z-score interval represents the same difference in normalized BMI units at any z-score level, unlike percentiles (WHO Expert Committee, 1995, p. 176). However, if BMI distributions are skewed, as they not infrequently are, then a specified z-score interval does not represent a constant difference in absolute BMI units at a given age. In addition, to the extent that standard deviations vary across ages, a specified interval between two z-scores may represent a difference in absolute BMI units that is not constant across ages. The effect is that a BMI z-score or percentile reflects an extensive series of transformations of the original weight and height data for a child. Weight and height are transformed into a BMI value and the BMI value in turn is transformed into an age- and sex-specific z-score based on a normalizing transformation of a smoothed version of observed reference data. A BMI z-score or percentile represents a measure of weight, adjusted for height, sex, and age, relative to a smoothed reference distribution, and not simply a measure of weight and height for a child. Not surprisingly, as body weight is correlated with fat mass and percentage body fat, BMI also tends to be correlated with percentage body fat (Wellens et al., 1996). However, as body weight is also correlated with muscle and lean mass, BMI tends to be correlated with muscle and lean mass as well and may be correlated with height within age groupings. Thus BMI is correlated with fatness but is not a precise measure of fatness. Additional complexities arise with children, where the indicator is not BMI itself, rather a sex- and age-specific percentile of BMI (Dietz & Bellizzi, 1999; Dietz & Robinson, 1998). The same BMI percentile does not represent the same percentage body fatness at different ages, for boys and girls, or among different race-ethnic groups. A BMI-for-age above a given value may be labeled obesity, but it is still a measure of excess weight, not necessarily of excess fat. Because of the wide variation in terminology, in this chapter we sometimes refer to ‘high BMI-for-age’ rather than to overweight or obesity. Reference data sets High BMI-for-age is defined relative to a reference distribution of BMI. There are numerous reference data sets for BMI in childhood. In many countries, BMI reference data are used or recommended as part of monitoring children’s growth (Al-Isa & Thalib, 2008; Ben et al., 2008; Cacciari et al., 2002; Cacciari et al., 2006; Cole et al., 1995; Cole & Roede, 1999; Conde & Monteiro, 2006; Del-Rio-Navarro et al., 2007; Inokuchi et al., 2006; Ji, 2005; Kato et al., 2008; Kuczmarski et al., 2000; (p.5) Mast et al., 2002; Ozturk et al., 2008; Rolland-Cachera et al., 1991; Savva et al., 2001; Williams, 2000). Such reference data are often based on representative

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High body mass index, overweight, and obesity in children: Definitions, terminology, and interpretation

data from a given country. For example, data for weight, height, BMI, and head circumference from 37,000 children from surveys representative of England, Scotland, and Wales were used to develop the 1990 British growth reference (Cole et al., 1998). In the United States, the Centers for Disease Control and Prevention (CDC) 2000 growth charts for the U.S. were developed from five nationally representative survey data sets (the National Health Examination Surveys II and III in the 1960s, the National Health and Nutrition Examination Survey (NHANES) I and II in the 1970s, and NHANES III, 1988–94) (Kuczmarski et al., 2002). They include sex-specific BMI-for-age growth curves for ages 2 through 19 years by single month of age (Kuczmarski, et al., 2002). All weight data from children ages 6 and above in 1988–94 were excluded because of the observed increase in weight in those years (Troiano & Flegal, 1998). The 2000 CDC charts are revised versions of the 1977 National Center for Health Statistics (NCHS) growth charts (Kuczmarski, et al., 2002). In 2006 the World Health Organization (WHO) released a new set of growth charts for children from birth to 5 years of age, based on data from the Multicentre Growth Reference Study (MGRS) conducted by WHO (WHO, 2006). The WHO charts are based on different principles from the aforementioned national growth charts. The WHO charts are intended to serve as growth standards, describing how children should grow. In contrast, national charts are generally descriptive, describing how children in the reference population did grow. The WHO charts are based on a selective sample of children from six sites around the world, consisting of children who were not subjected to socioeconomic constraints on growth, who were healthy term singleton births, whose mothers did not smoke before or after pregnancy, and who were fed according to MGRS feeding recommendations for breast and complementary feeding. The growth of these children was considered to represent optimal growth. Although the children were selected in a different fashion than for other national and international references, the WHO charts are otherwise constructed along similar lines to other charts and consist of descriptive percentiles from this select population. WHO subsequently used most of the same NHANES data that had been used for the CDC growth charts in order to develop a growth reference for older children and adolescents (de Onis et al., 2007), with modifications to delete the heavier children in the NHANES data sets. Reference sets of charts, such as the 1990 UK reference, the 2000 CDC Growth Charts and the WHO charts, are intended for clinical use in monitoring children’s growth over the entire range of growth. For example, an important use of the WHO charts is to monitor and assess acute undernutrition (Seal & Kerac, 2007). The use of selected percentiles of such charts to define overweight and obesity is a secondary purpose. There are also several sets of BMI reference data that are intended specifically to define childhood overweight or obesity, rather than to be used for clinical monitoring of growth patterns. These include only a few cut-off values. One reference set of BMI values that has been widely used consists of sex-specific smoothed 85th and 95th percentiles for single year of age from 6 to 19 years, based on data from the first National Health and Nutrition Examination Survey (NHANES I, 1971–74) in the United States, developed by Must et al. (Must et al., 1991). In 1995, a WHO Expert Committee recommended the use of these reference values (WHO Expert Committee on Physical Status: the Use and Interpretation of Anthropometry, 1995).

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High body mass index, overweight, and obesity in children: Definitions, terminology, and interpretation

Although the 1991 Must et al. reference values were considered to represent the 85th and 95th percentiles of the distribution of BMI in NHANES I, in fact, because of some slight oversmoothing of the data for girls, the Must et al. values for the 85th percentile are systematically lower than the empirical 85th percentile from the same data set and are more similar to the 80th percentile than to the 85th (Flegal, 1999). (p.6) As a result when the Must et al. values are used the prevalence of BMI above the 85th percentile tends to be high for adolescent girls. In 2000, Cole and colleagues published a set of smoothed sex-specific BMI cut-off values based on six nationally representative data sets from Brazil, Great Britain, Hong Kong, the Netherlands, Singapore, and the United States (Cole et al., 2000). The U.S. data used were the same as those from which the 2000 CDC growth charts were derived, excluding NHANES III data. The selection of data sets was based on specified criteria including a large nationally representative sample, minimum age ranges of 6 to 18 years, and appropriate quality control. These values, often referred to as the International Obesity Task Force (IOTF) cut-off values, represent cut-off points chosen as the percentiles that matched the adult cut-offs of a BMI of 25 and 30 at age 18 years. The IOTF, then headquartered at the Rowett Research Institute (UK), was an ad hoc independent group of scientists from different countries that was constituted in 1996 with the mission to inform the world about the urgency of the problem of obesity and to persuade governments to act. (The IOTF later merged with the International Association for the Study of Obesity.) The Cole (IOTF) reference grew out of a 1997 workshop held by the IOTF and was developed to provide a suggested common basis for prevalence estimates internationally. The goal was to develop BMI criteria that could be used for international comparisons of prevalence without depending on using solely U.S. reference data and without using a specified percentile, such as the 85th or 95th percentile of a specific population. The IOTF cut-offs were not intended as clinical definitions and were not intended to replace national reference data, but rather to provide a common set of definitions that researchers and policy makers in different countries could use for descriptive and comparative purposes internationally. It should be further noted that the IOTF recommendations were based on a small number of data sets that were available at the time and were not intended as a comprehensive or final analysis. Several discussions on the use of national versus international reference data have been published (Chinn & Rona, 2002; Reilly, 2002; Onyango, 2008). Selection of cut-off values In adults, the cut-offs to define obesity or overweight are based on fixed BMI values approximately related to health risk (NIH, 1998). In children there are no risk-based fixed values of BMI used to determine cut-off values, because it is unclear what risk-related criteria to use. The long time span before most adverse outcomes appear makes finding risk related cut-offs difficult (Ayer & Steinbeck, 2010; Lloyd et al., 2010). Consequently, in childhood statistical definitions of high BMI-for-age in terms of percentiles or z-scores relative to a specified reference population are often used to define high BMI-for-age (Barlow & Dietz, 1998; Himes & Dietz, 1994).

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High body mass index, overweight, and obesity in children: Definitions, terminology, and interpretation

Despite their common use, the rationale for using the 85th and 95th percentiles has not been very clearly spelled out. In terms of z-scores, for younger children WHO has defined obesity as a z-score above 3 and overweight as a z-score above 2, but not with an explicit justification for these precise cut-off values (World Health Organization, 2008). Cut-off values are not necessarily exact. For both adults and children, many cut-off values of percentiles or z-scores for BMI end in 5 or 0. The propensity to choose values ending in 5 or 0 has been repeatedly noted in studies of blood pressure measurements and has been demonstrated to occur in other situations, including clinic arrival times and even in pathology reports (Hayes, 2008, 2009; Himes, 1999). This digit preference may also affect the choice of cut-off values for BMI. One feature of statistical definitions that has been little remarked on is that they include the assumption that in the reference population, the prevalence is exactly the same for every sex and age group. For example, if obesity is defined as a BMI-for-age at or above the 95th percentile, then in the reference population, 5% of 6-year-olds are considered obese, 5% of 7year-olds are considered obese, and so forth up to 5% of 19-year-olds. This is also the case with the definitions that are keyed (p.7) to the adult BMI values of 25 and 30 at age 18. Those definitions are also percentiles that are constant over age and sex in the reference distribution, even though the exact percentile level is not specified. The variety of reference data and cut-off values mean that there is a plethora of different definitions of childhood overweight or obesity for calculating prevalence estimates. Numerous articles have compared the use of different definitions with the same population (Abrantes et al., 2003; Al-Sendi et al., 2003; Chinn & Rona, 2002; Flegal et al., 2001; Fu et al., 2003; Huerta et al., 2007; Jackson et al., 2007; Janssen et al., 2005; Kain et al., 2002; Mei et al., 2008; O'Neill et al., 2007; Serra-Majem et al., 2007; Telford et al., 2008; Valerio et al., 2003; Vidal et al., 2006; Vieira et al., 2007; Wang & Adair, 2001; Wang & Wang, 2002; Willows et al., 2007; Yngve et al., 2008; Zimmermann et al., 2004). For example, in one analysis, three different sets of BMI reference values were used to estimate the prevalence of overweight among children in the United States (Flegal et al., 2001). The three sets of BMI reference values resulted in similar but not identical estimates (Flegal et al., 2001). For young girls, estimates based on the Must et al. reference values (1991) were much higher than estimates based on the CDC (Kuczmarski et al., 2002) and Cole (2000) references. The Cole (IOTF) reference gave rise to lower estimates for young children and higher estimates for older children than the Must and CDC references. As seen repeatedly, the various definitions do not give the same results. The direction of the difference between two definitions for a given age and sex value can be determined simply by comparing the BMI values for the two definitions, but this does not show the average effect on prevalence estimates over a broader age range or the magnitude of the effect. Terminology The terminology used in different studies varies considerably. Some refer to ‘overweight’, some to ‘obesity’ and some to ‘at risk for overweight’. Even when the same term is used (e.g. ‘overweight’) the meaning of that term is often not the same in different countries or across studies.

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High body mass index, overweight, and obesity in children: Definitions, terminology, and interpretation

In 1995 a WHO expert committee listed ‘heaviness’ as a descriptive term to describe high BMI and noted that the term ‘overweight’ used for high BMI implied obesity (WHO Expert Committee, 1995, p. 163). The convention of using the term overweight for BMI levels indicative of possible obesity was also followed by several expert committees in the United States in the 1990s (Barlow & Dietz, 1998; Himes & Dietz, 1994). These committees recommended using a BMI-for-age at or above the 95th percentile of a specified reference population to screen for obesity in adolescents and younger children, noting that these values were not designed to provide clinical cut-points, but rather to serve as screening values. The committee recommendations were that children and adolescents with BMI values at or above the 95th percentile of a suitable reference population undergo an in-depth assessment, stating that ‘in-depth assessments are required to distinguish positively screened adolescents who are truly obese, to identify underlying diagnoses and to provide a basis for prescribing treatment’. The 1994 expert committee drew a distinction between overweight and obesity. According to their report (Himes & Dietz, 1994), ‘The committee reserved the use of the term obesity for a condition characterized by excess body fat. … the committee elected to define excess body mass as overweight and to rely on additional measures to distinguish those who are obese from those who are overweight but may not be obese’. The same expert committees considered that children with BMI values between the 85th and 95th percentiles might also possibly be obese, although with a lower probability. Thus for these children, it was recommended that they be referred to a second-level screen, including consideration of family history, blood pressure, total cholesterol, large prior increment in BMI, and concern about weight. These children would be referred for the in-depth evaluation only if they were positive for any of the items on the second-level screen. The committees used the designation of (p.8) ‘at risk for overweight’ for BMI values between the 85th and the 95th percentiles of BMI for age. Although this is sometimes interpreted as a designation for a child who is at risk for becoming overweight in the future, that was not the original intention of the term. The category as defined by the expert committees (Barlow & Dietz, 1998; Himes & Dietz, 1994) was intended to identify children who might be obese, in the sense of excess body fat, but who should undergo a second-level screen (as described earlier) to evaluate whether they should be referred for an in-depth assessment. The term ‘possible risk of overweight’ has been used in a similar sense by WHO (2008). Following these expert committee recommendations, in the U.S., ‘overweight’ was defined as a BMI at or above the 95th percentile of the 2000 CDC growth charts, and ‘at risk for overweight’ was defined as a BMI between the 85th and the 95th percentile (Hedley et al., 2004; Ogden et al., 2002; Troiano & Flegal, 1998). Changes in terminology More recent changes in terminology have been undertaken to be consistent with adult terminology and to emphasize the seriousness of the problem of high BMI among children, consistent with research indicating the importance of the role that medical language plays in perceptions of illness (Young et al., 2008). The Institute of Medicine report on ‘Preventing Childhood Obesity’ (Koplan et al., 2005) retained the 95th percentile as a cut-off value, but changed the terminology, stating that, ‘The committee recognizes that it has been customary to use the term “overweight” instead of “obese” to refer to children with BMI values above the age-

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High body mass index, overweight, and obesity in children: Definitions, terminology, and interpretation

and gender-specific 95th percentiles However, the term “obese” more effectively conveys the seriousness, urgency, and medical nature of this concern than does the term “overweight,” thereby reinforcing the importance of taking immediate action’. Following along these lines, a subsequent expert committee convened by the American Medical Association (Krebs et al., 2007) retained the two cut-off values of the 85th and 95th percentile recommended by previous committees but used different terminology, referring to BMI-for-age from the 85th up to the 95th percentile as ‘overweight’ and to BMI-for-age at or above the 95th percentile as ‘obesity’, stating that ‘The compelling reasons for this revision are clinical. The term obesity denotes excess body fat more accurately and reflects the associated serious health risks more clearly than does the term overweight, which is not recognized as a clinical term for high adiposity’. With these definitions, the two categories of overweight and obesity are mutually exclusive. As a result, the definition of overweight as a BMI-for-age at or above the 95th percentile by the 1994 committee and the definition of overweight by the 2007 committee as a BMI-for-age between the 85th and 95th percentile have no overlap. In further recognition of the importance of language, the committee also recommended the use of more ‘neutral’ terms when discussing weight issues with families, stating that ‘Therefore, the expert committee recommends the use of the clinical terms overweight and obesity for documentation and risk assessment but the use of different terms in the clinician’s office, to avoid an inference of judgment or repugnance.’ Some concerns have been raised regarding the possible adverse effects of labeling and stigmatization (Krebs et al., 2007; Whitlock et al., 2005). However, in 2005, the U.S. Preventive Services Task Force (USPSTF) found no direct evidence to make conclusions about potential harms, such as poorer self-concept or disordered eating, from screening (Whitlock et al., 2005). Barriers to consensus The issue of different definitions is not new but has been discussed extensively in various previous publications (for example Neovius et al., 2004). Guillaume’s summary from 1999 still applies today: ‘Available data allow neither a meaningful international estimation of the prevalence of (p.9) obesity nor international comparisons. Although associated with considerable problems, this situation can be improved with an international consensus which, by necessity, will be riddled with uncertainties and compromises’. (Guillaume, 1999). Although there are many different proposals, guidelines, and recommendations, a basic problem is the lack of strong evidence for any precise definition. The Endocrine Society clinical practice guidelines (August et al., 2008) make a strong recommendation for classifying children as overweight if their BMI is between the 85th and 95th percentiles and as obese if their BMI is at or above the 95th, but in contrast to the strength of the recommendation, they describe the evidence for this recommendation as of ‘very low quality’. The U.S. Preventive Services Task Force report (Whitlock et al., 2005) summarized the considerable gaps in knowledge of the links between childhood weight and future health outcomes. One result of these gaps in knowledge is that the implications of a specific level of BMI for children’s future health are unclear. This was noted in the expert committee report (Himes & Dietz, 1994) published in 1994: ‘Unfortunately, little published information exists regarding

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High body mass index, overweight, and obesity in children: Definitions, terminology, and interpretation

specific degrees of overweight in adolescence and current or subsequent health-related outcomes …. Further, because of the low prevalence of the sequelae of obesity among adolescents, specific cutoff values for BMI or other measures of overweight in adolescence associated with health risks have not been established’. The same concern was echoed in 2005 in a commentary by the Childhood Obesity Task Force of the U.S. Preventive Services Task Force (Moyer et al., 2005), which stated: ‘We do not know the best way to identify children who are at risk for future adverse health outcomes due to obesity or overweight. Although BMI is a convenient and widely agreed-on measure of obesity, it is not clear what BMI at any given age is associated with future good health’. Reviews by Reilly (Reilly et al., 2003) and by Must and Strauss (Must & Strauss, 1999) delineate the numerous health risks associated with high BMI in children. Higher BMI among children is associated with higher levels of blood pressure, serum lipids, and other factors (Freedman et al., 1999) that in adults are associated with higher cardiovascular risk. Evidence linking children’s BMI levels to adult cardiovascular disease is limited and raises many methodological issues (Ayer & Steinbeck, 2010; Baker et al., 2007; Bibbins-Domingo et al., 2007; Lloyd et al., 2010). Increases in type 2 diabetes among children are of concern. However, available evidence suggests that the prevalence is still quite low and that many of these cases occur in children with very high BMIs, often in the range of 35 to 40, that would be considered grade 2 or grade 3 obesity in adults (Goran et al., 2008). A recent estimate of the incidence of type 2 diabetes among children in the UK arrived at an estimate of 0.53 cases per 100,000 children per year (Haines et al., 2007). Some research tracking childhood BMI over time has suggested that the trajectory of BMI change may be a more important indicator of risk for adult disease than a given BMI at any one point in time. For example Bhargava et al. (2004) found that ‘Subjects with impaired glucose tolerance or diabetes typically had a low body-mass index up to the age of two years, followed by an early adiposity rebound (the age after infancy when body mass starts to rise) and an accelerated increase in body-mass index until adulthood. However, despite an increase in body-mass index between the ages of 2 and 12 years, none of these subjects were obese at the age of 12 years’. Similarly Barker et al. (2005) found that ‘The mean body size of children who had coronary events as adults was below average at birth. At two years of age the children were thin; subsequently, their body-mass index (BMI) increased relative to that of other children and had reached average values by 11 years of age’. Uses of these classifications Definitions of overweight and obesity are used for several different purposes. For use within a single country for public health purposes such as surveillance, often a national reference will be (p.10) more suitable, allowing for comparison of children to a reference group of children from the same country. For international comparisons of prevalence, a consistent definition should be used across countries. However, it is not yet clear that any one definition is better than another for this purpose. A given definition may be more suitable for one country than for another country. Furthermore, given the limitations of BMI as a measure of body fatness and the likely variation by not only age and sex but also by race-ethnic groupings, any international comparisons should be interpreted cautiously, particularly those between dissimilar countries. The WHO charts are based on a sample selected to represent normal growth in healthy children but nonetheless suffer from some of the same issues that affect other definitions, including the

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High body mass index, overweight, and obesity in children: Definitions, terminology, and interpretation

use of BMI as an imperfect measure of adiposity and the difficulty in choosing an appropriate cut-off value. The IOTF definitions resolve the issue of choosing a cut-off value by linking to the adult levels, but this linkage serves only to choose the percentiles used as cut-off values and does not substitute for a functional definition. In general, although ‘overweight’ and ‘obesity’ are useful descriptive terms, it might be useful to consider ways of making more comprehensive comparisons of BMI distributions across countries without or in addition to these descriptive terms. Children are defined as overweight or obese for population surveillance and screening purposes, using a variety of BMI cut-points. However, these children do not necessarily have clinical complications or health risks related to over-fatness. According to the Centers for Disease Control and Prevention (Centers for Disease Control and Prevention): ‘In-depth assessments are required to determine if children and adolescents with BMI-for-age 〉 95th percentile are truly overfat and at increased risk for health complications’. Consistent with this approach, in the UK, different cut-off values are used for clinical use than for surveillance. The clinical guideline published by the National Institute for Health and Clinical Excellence (NICE) defined overweight and obesity for clinicians as the 91st and 98th percentiles, respectively (NICE, 2006). For purposes of surveillance, however, the 85th and 95th percentiles are used for government statistics (Jotangia et al., 2005). For specific conditions, BMI is an important part of a screening algorithm. For example, the American Diabetes Association (2000) recommends screening for diabetes in children with BMI at or above the 85th percentile and have in addition two of the following factors: 1) family history of type 2 diabetes; 2) membership in specified race-ethnic groups (American Indians, African Americans, Hispanic Americans, Asians/South Pacific Islanders); 3) signs of insulin resistance. For dyslipidemia, it is recommended that all children with BMI-for-age at or above the 85th percentile should be screened (Daniels & Greer, 2008). Despite recommendations that BMI be considered as a screening, rather than as a diagnostic tool (Barlow, 2007), BMI-based categories may be considered as diagnoses (for example, Benson et al., 2009), perhaps encouraged to some extent by recommendations for the use of clinical terminology. The use of BMI as part of a screening algorithm does not in fact require a particular definition or a particular label and can be separate from any definitions used for prevalence estimates. Considerable research efforts have been devoted to how to choose cutpoints for screening, which is generally done taking into account the expected yield and a balance of costs and benefits. Interventions are designed to reduce the risk of future events, and it might be decided to intervene in a given way for a given BMI level again without the need for a label. Current and future research efforts continue to address the relationship between BMI and body fat in the general population and in different race/ethnic groups. These efforts may clarify the use of BMI as an indicator of body fatness in children, as well as of the value of indicators other than BMI, such as waist circumference. Research continues on the development of risk-based cut-points. The percentile or z-score cut-points have digit preference, are statistically based, and are not based on a priori health risk. In addition, because the relationship between BMI and adiposity (p.11) varies by sex, age, and race/ethnicity, risk-based cut-points may also vary. It

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High body mass index, overweight, and obesity in children: Definitions, terminology, and interpretation

might be useful to consider what BMI cut-points best predict future health risks and how efficiently to screen for such risks. The answers may be different for different populations. In addition, rather than depending solely on BMI to make screening decisions, it is likely to be useful to also consider other factors, including not only race-ethnicity, sex, and age, but also factors such as family history. Further examination of the relation between various health measures and BMI measured on a continuous basis may provide additional valuable information (Bell et al., 2007). There has also been recent interest in extremely obese children, in part in the context of possible bariatric surgery for adolescents (Inge et al., 2007). The current reference distributions for BMI are generally not very suitable for use in classifying or tracking very heavy children. Most reference data sets use data from several decades ago and have few very heavy children. In addition, several charts deliberately excluded the heaviest children. For example, in the construction of the WHO charts, the data were trimmed before constructing the charts specifically in order to exclude heavier children (2006). Similarly, in the construction of the CDC charts, it was decided not to use the most recent data because the children in that survey were heavier on average than children in earlier surveys (Kuczmarski et al., 2002). In general, data are sparse at the extremes of the BMI distributions and modelling data in the extreme tails is difficult. The use of cut-off z-scores as high as 3 represent the 99.8th percentile, which is difficult to estimate with any precision. The current reference populations for BMI may not provide reasonable cut-points for extremely obese children. Expressing high BMI values as a percentage of the 95th percentile can provide a flexible approach to describing and tracking heavier children (Flegal et al., 2009).

Conclusions Continued efforts to evaluate existing references in terms of growth over the whole range of body sizes are valuable and should not be limited just to evaluation of overweight and obesity (Roelants et al., 2009). Evidence suggests that the associations of childhood BMI with adult disease may be related to growth trajectories, not necessarily to BMI at any one point in time. The continued use of BMI-based definitions has many practical advantages, including familiarity and relative ease of obtaining weight and height measurements. However, some of the limitations of such definitions should also be recognized, including the statistical rather than clinical definition of cut-off values and the approximate nature of BMI as a measure of body fatness. Despite their limitations, BMI-based definitions of overweight and obesity provide working practical definitions that are valuable for general public health surveillance and screening. References Bibliography references: Abrantes, M.M., Lamounier, J.A., & Colosimo, E.A. (2003) Comparison of body mass index values proposed by Cole et al. (2000) and Must et al. (1991) for identifying obese children with weightfor-height index recommended by the World Health Organization. Public Health Nutrition 6(3), 307–311.

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Al-Isa, A.N. & Thalib, L. (2008) Body mass index of Kuwaiti adolescents aged 10–14 years: reference percentiles and curves. Eastern Mediterranean Health Journal 14(2), 333–343. Al-Sendi, A.M., Shetty, P., & Musaiger, A.O. (2003) Prevalence of overweight and obesity among Bahraini adolescents: a comparison between three different sets of criteria. European Journal of Clinical Nutrition 57(3), 471–474. American Diabetes Association (2000) Type 2 diabetes in children and adolescents. Diabetes Care 23(3), 381–389. August, G.P., Caprio, S., Fennoy, I., et al. (2008) Prevention and treatment of pediatric obesity: an endocrine society clinical practice guideline based on expert opinion. The Journal of Clinical Endocrinology and Metabolism 93(12), 4576–4599. Ayer, J. & Steinbeck, K. (2010) Placing the cardiovascular risk of childhood obesity in perspective. International Journal of Obesity 34(1), 4–5. Baker, J.L., Olsen, L.W., & Sorensen, T.I. (2007) Childhood body-mass index and the risk of coronary heart disease in adulthood. New England Journal of Medicine 357(23), 2329–2337. Barker, D.J., Osmond, C., Forsen, T.J., Kajantie, E., & Eriksson, J.G. (2005) Trajectories of growth among children who have coronary events as adults. New England Journal of Medicine 353(17), 1802–1809. Barlow, S.E. (2007) Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 120(Suppl 4), S164–S192. Barlow, S.E. & Dietz, W.H. (1998) Obesity evaluation and treatment: Expert Committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services. Pediatrics 102(3), E29. Bell, L.M., Byrne, S., Thompson, A., et al. (2007) Increasing body mass index z-score is continuously associated with complications of overweight in children, even in the healthy weight range. The Journal of Clinical Endocrinology and Metabolism 92(2), 517–522. Ben, A.H., Jelidi, J., Bouguerra, R., et al. (2008) Tunisian children reference for body mass index and prevalence of obesity. Tunisian Medicine 86(10), 906–911. Benn, R.T. (1971) Some mathematical properties of weight-for-height indices used as measures of adiposity. British Journal of Preventive and Social Medicine 25(1), 42–50. Benson, L., Baer, H.J., & Kaelber, D.C. (2009) Trends in the diagnosis of overweight and obesity in children and adolescents: 1999–2007. Pediatrics 123(1), e153–e158. Bhargava, S.K., Sachdev, H.S., Fall, C.H., et al. (2004) Relation of serial changes in childhood body-mass index to impaired glucose tolerance in young adulthood. New England Journal of Medicine 350(9), 865–875.

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Bibbins-Domingo, K., Coxson, P., Pletcher, M.J., Lightwood, J., & Goldman, L. (2007) Adolescent overweight and future adult coronary heart disease. New England Journal of Medicine 357(23), 2371–2379. Cacciari, E., Milani, S., Balsamo, A., et al. (2002) Italian cross-sectional growth charts for height, weight and BMI (6–20 y). European Journal of Clinical Nutrition 56(2), 171–180. Cacciari, E., Milani, S., Balsamo, A., et al. (2006) Italian cross-sectional growth charts for height, weight and BMI (2 to 20 yr). Journal of Endocrinological Investigation 29(7), 581–593. Centers for Disease Control and Prevention. (2009) CDC growth chart training modules: overweight children and adolescents: recommendations to screen, assess and manage. (Accessed 12 August 2009) Chinn, S. & Rona, R.J. (2002) International definitions of overweight and obesity for children: a lasting solution? Annals of Human Biology 29(3), 306–313. Cole, T.J. (1979) A method for assessing age-standardized weight-for-height in children seen cross-sectionally. Annals of Human Biology 6(3), 249–268. Cole, T.J. (1990) The LMS method for constructing normalized growth standards. European Journal of Clinical Nutrition 44(1), 45–60. Cole, T.J., Bellizzi, M.C., Flegal, K.M., & Dietz, W.H. (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320(7244), 1240–1243. Cole, T.J. & Roede, M.J. (1999) Centiles of body mass index for Dutch children aged 0–20 years in 1980 – a baseline to assess recent trends in obesity. Annals of Human Biology 26(4), 303–308. Cole, T.J., Freeman, J.V., & Preece, M.A. (1995) Body mass index reference curves for the UK, 1990. Archives of Disease in Childhood 73(1), 25–29. Cole, T.J., Freeman, J.V., & Preece, M.A. (1998) British 1990 growth reference centiles for weight, height, body mass index and head circumference fitted by maximum penalized likelihood. Statistics in Medicine 17(4), 407–429. Conde, W.L. & Monteiro, C.A. (2006) Body mass index cutoff points for evaluation of nutritional status in Brazilian children and adolescents. Journal of Pediatrics (Rio J.) 82(4), 266–272. Daniels, S.R. & Greer, F.R. (2008) Lipid screening and cardiovascular health in childhood. Pediatrics 122(1), 198–208. De Onis, M., Onyango, A.W., Borghi, E., Siyam, A., Nishida, C., & Siekmann, J. (2007) Development of a WHO growth reference for school-aged children and adolescents. Bulletin of World Health Organization 85(9), 660–667.

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Del-Rio-Navarro, B.E., Velazquez-Monroy, O., Santos-Preciado, J.I., et al. (2007) Mexican anthropometric percentiles for ages 10–18. European Journal of Clinical Nutrition 61(8), 963– 975. Dietz, W.H. & Bellizzi, M.C. (1999) Introduction: the use of body mass index to assess obesity in children. American Journal of Clinical Nutrition 70(1), 123S–125S. Dietz, W.H. & Robinson, T.N. (1998) Use of the body mass index (BMI) as a measure of overweight in children and adolescents. Journal of Pediatrics 132(2), 191–193. Flegal, K.M. (1999) Curve smoothing and transformations in the development of growth curves. American Journal of Clinical Nutrition 70(1), 163S–165S. Flegal, K.M., Ogden, C.L., Wei, R., Kuczmarski, R.L., & Johnson, C.L. (2001) Prevalence of overweight in US children: comparison of US growth charts from the Centers for Disease Control and Prevention with other reference values for body mass index. American Journal of Clinical Nutrition 73(6), 1086–1093. Flegal, K.M., Wei, R., Ogden, C.L., Freedman, D.S., Johnson, C.L., & Curtin, L.R. (2009) Characterizing extreme values of body mass index for age by using the 2000 Centers for Disease Control and Prevention growth charts. American Journal of Clinical Nutrition 90(5), 1314–1320. Freedman, D.S., Dietz, W.H., Srinivasan, S.R., & Berenson, G.S. (1999) The relation of overweight to cardiovascular risk factors among children and adolescents: the Bogalusa Heart Study. Pediatrics 103(6 Pt 1), 1175–1182. Fu, W.P., Lee, H.C., Ng, C.J., et al. (2003) Screening for childhood obesity: international vs population-specific definitions. Which is more appropriate? International Journal of Obesity 27(9), 1121–1126. Goran, M.I., Davis, J., Kelly, L., et al. (2008) Low prevalence of pediatric type 2 diabetes: where's the epidemic? Journal of Pediatrics 152(6), 753–755. Guillaume, M. (1999) Defining obesity in childhood: current practice. American Journal of Clinical Nutrition 70(1 Part 2), 126S–130S. Haines, L., Wan, K.C., Lynn, R., Barrett, T.G., & Shield, J.P. (2007) Rising incidence of type 2 diabetes in children in the U.K. Diabetes Care 30(5), 1097–1101. Hayes, S.J. (2008) Does terminal digit preference occur in pathology? Journal of Clinical Pathology 61(8), 975–976. Hayes, S.J. (2009) Benford's law in relation to terminal digit preference. Journal of Clinical Pathology 62(6), 575–576. Hedley, A.A., Ogden, C.L., Johnson, C.L., Carroll, M.D., Curtin, L.R., & Flegal, K.M. (2004) Prevalence of overweight and obesity among US children, adolescents, and adults, 1999–2002. JAMA: the Journal of the American Medical Association 291(23), 2847–2850.

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Himes, J.H. (1999) Agreement among anthropometric indicators identifying the fattest adolescents. International Journal of Obesity 23 Suppl (2), S18–S21. Himes, J.H. & Dietz, W.H. (1994) Guidelines for overweight in adolescent preventive services: recommendations from an expert committee. The Expert Committee on Clinical Guidelines for Overweight in Adolescent Preventive Services. American Journal of Clinical Nutrition 59(2), 307–316. Huerta, M., Gdalevich, M., Tlashadze, A., et al. (2007) Appropriateness of US and international BMI-for-age reference curves in defining adiposity among Israeli school children. European Journal of Pediatrics 166(6), 573–578. Inge, T.H., Xanthakos, S.A., & Zeller, M.H. (2007) Bariatric surgery for pediatric extreme obesity: now or later? International Journal of Obesity 31(1), 1–14. Inokuchi, M., Hasegawa, T., Anzo, M., & Matsuo, N. (2006) Standardized centile curves of body mass index for Japanese children and adolescents based on the 1978–1981 national survey data. Annals of Human Biology 33(4), 444–453. Jackson, R.T., Rashed, M., Al-Hamad, N., Hwalla, N., & Al-Somaie, M. (2007) Comparison of BMI-for-age in adolescent girls in 3 countries of the Eastern Mediterranean Region. Eastern Mediterranean Health Journal 13(2), 430–440. Janssen, I., Katzmarzyk, P.T., Srinivasan, S.R., et al. (2005) Utility of childhood BMI in the prediction of adulthood disease: comparison of national and international references. Obesity Research 13(6), 1106–1115. Ji, C.Y. (2005) Report on childhood obesity in China (1) – body mass index reference for screening overweight and obesity in Chinese school-age children. Biomedical and Environmental Sciences 18(6), 390–400. Jotangia, D., Moody, A., Stamatakis, E., & Wardle, H. (2005) Obesity among children under 11.London: Department of Health. (Accessed 12 November 2009.) Kain, J., Uauy, R., Vio, F., & Albala, C. (2002) Trends in overweight and obesity prevalence in Chilean children: comparison of three definitions. European Journal of Clinical Nutrition 56(3), 200–204. Kato, N., Sato, K., Takimoto, H., & Sudo, N. (2008) BMI for age references for Japanese children – based on the 2000 growth survey. Asia-Pacific Journal of Public Health 20 Suppl 118–127. Keys, A., Fidanza, F., Karvonen, M.J., Kimura, N., & Taylor, H.L. (1972) Indices of relative weight and obesity. Journal of Chronic Diseases 25(6), 329–343. Khosla, T. & Lowe, C.R. (1967) Indices of obesity derived from body weight and height. British Journal of Preventive and Social Medicine 21(3), 122–128.

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Koplan, J.P., Liverman, C.T., & Kraak, V.I. (2005) Preventing childhood obesity: health in the balance: executive summary. Journal of the American Dietetic Association 105(1), 131–138. Krebs, N.F., Himes, J.H., Jacobson, D., Nicklas, T.A., Guilday, P., & Styne, D. (2007) Assessment of child and adolescent overweight and obesity. Pediatrics 120 Suppl 4 S193–S228. Kuczmarski, R.J., Ogden, C.L., Grummer-Strawn, L.M., et al. (2000) CDC growth charts: United States. Advance Data 314, 1–27. Kuczmarski, R.J., Ogden, C.L., Guo, S.S., et al. (2002) 2000 CDC growth charts for the United States: methods and development. Vital Health Statistics 11(246), 1–190. Lloyd, L.J., Langley-Evans, S.C., & McMullen, S. (2010) Childhood obesity and adult cardiovascular disease risk: a systematic review. International Journal of Obesity 34(1), 18–28. Mast, M., Langnase, K., Labitzke, K., Bruse, U., Preuss, U., & Muller, M.J. (2002) Use of BMI as a measure of overweight and obesity in a field study on 5–7 year old children. European Journal of Nutrition 41(2), 61–67. Mei, Z., Ogden, C.L., Flegal, K.M., & Grummer-Strawn, L.M. (2008) Comparison of the prevalence of shortness, underweight, and overweight among US children aged 0 to 59 months by using the CDC 2000 and the WHO 2006 growth charts. Journal of Pediatrics 153(5), 622–628. Moyer, V.A., Klein, J.D., Ockene, J.K., Teutsch, S.M., Johnson, M.S., & Allan, J.D. (2005) Screening for overweight in children and adolescents: where is the evidence? A commentary by the childhood obesity working group of the US Preventive Services Task Force. Pediatrics 116(1), 235–238. Must, A., Dallal, G.E., & Dietz, W.H. (1991) Reference data for obesity: 85th and 95th percentiles of body mass index (wt/ht2) and triceps skinfold thickness. American Journal of Clinical Nutrition 53(4), 839–846. Must, A. & Strauss, R.S. (1999) Risks and consequences of childhood and adolescent obesity. International Journal of Obesity 23 Suppl 2, S2–S11. National Institutes of Health (1998) Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults–the evidence report. Obesity Research 6 Suppl 2, 51S–209S. National Institute for Health and Clinical Excellence (2006) Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. Clinical Guidelines CG43. London: National Institute for Health and Clinical Excellence. (Accessed 1 November 2009) Neovius, M., Linne, Y., Barkeling, B., & Rossner, S. (2004) Discrepancies between classification systems of childhood obesity. Obesity Reviews 5(2), 105–114.

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O'Neill, J.L., McCarthy, S.N., Burke, S.J., et al. (2007) Prevalence of overweight and obesity in Irish school children, using four different definitions. European Journal of Clinical Nutrition 61(6), 743–751. Ogden, C.L., Flegal, K.M., Carroll, M.D., & Johnson, C.L. (2002) Prevalence and trends in overweight among US children and adolescents, 1999–2000. JAMA: the Journal of the American Medical Association 288(14), 1728–1732. Onyango, A.W. (2008) Approaches to developing cut-off points for overweight and obesity in childhood. International Journal of Pediatric Obesity 3 Suppl 2, 33–35. Ozturk, A., Mazicioglu, M.M., Hatipoglu, N., et al. (2008) Reference body mass index curves for Turkish children 6 to 18 years of age. Journal of Pediatric Endocrinology and Metabolism 21(9), 827–836. Reilly, J.J. (2002) Assessment of childhood obesity: national reference data or international approach? Obesity Research 10(8), 838–840. Reilly, J.J., Methven, E., McDowell, Z.C., et al. (2003) Health consequences of obesity. Archives of Disease in Childhood 88(9), 748–752. Roelants, M., Hauspie, R., & Hoppenbrouwers, K. (2009) Breastfeeding, growth and growth standards: performance of the WHO growth standards for monitoring growth of Belgian children. Annals of Human Biology 37(1), 2–9. Rolland-Cachera, M.F., Cole, T.J., Sempe, M., Tichet, J., Rossignol, C., & Charraud, A. (1991) Body Mass Index variations: centiles from birth to 87 years. European Journal of Clinical Nutrition 45(1), 13–21. Savva, S.C., Kourides, Y., Tornaritis, M., Epiphaniou-Savva, M., Tafouna, P., & Kafatos, A. (2001) Reference growth curves for cypriot children 6 to 17 years of age. Obesity Research 9(12), 754– 762. Seal, A. & Kerac, M. (2007) Operational implications of using 2006 World Health Organization growth standards in nutrition programmes: secondary data analysis. BMJ 334(7596), 733. Serra-Majem, L., Ribas-Barba, L., Perez-Rodrigo, C., Ngo, J., & Aranceta, J. (2007) Methodological limitations in measuring childhood and adolescent obesity and overweight in epidemiological studies: does overweight fare better than obesity? Public Health Nutrition 10(10A), 1112–1120. Telford, R.D., Cunningham, R.B., Daly, R.M., et al. (2008) Discordance of international adiposity classifications in Australian boys and girls – the LOOK study. Annals of Human Biology 35(3), 334–341. Troiano, R.P. & Flegal, K.M. (1998) Overweight children and adolescents: description, epidemiology, and demographics. Pediatrics 101(3 Pt 2), 497–504.

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Valerio, G., Scalfi, L., De, M.C., Franzese, A., Tenore, A., & Contaldo, F. (2003) Comparison between different methods to assess the prevalence of obesity in a sample of Italian children. Journal of Pediatric Endocrinology and Metabolism 16(2), 211–216. Vidal, E., Carlin, E., Driul, D., Tomat, M., & Tenore, A. (2006) A comparison study of the prevalence of overweight and obese Italian preschool children using different reference standards. European Journal of Pediatrics 165(10), 696–700. Vieira, M.F., Araujo, C.L., Neutzling, M.B., Hallal, P.C., & Menezes, A.M. (2007) Diagnosis of overweight and obesity in adolescents from the 1993 Pelotas Birth Cohort Study, Rio Grande do Sul State, Brazil: comparison of two diagnostic criteria. Cadernos de Saude Publica 23(12), 2993–2999. Wang, Y. & Adair, L. (2001) How does maturity adjustment influence the estimates of overweight prevalence in adolescents from different countries using an international reference? International Journal of Obesity 25(4), 550–558. Wang, Y. & Wang, J.Q. (2002) A comparison of international references for the assessment of child and adolescent overweight and obesity in different populations. European Journal of Clinical Nutrition 56(10), 973–982. Weigley, E.S. (2000) Adolphe Quetelet. American Journal of Clinical Nutrition 71(3), 853. Wellens, R.I., Roche, A.F., Khamis, H.J., Jackson, A.S., Pollock, M.L., & Siervogel, R.M. (1996) Relationships between the Body Mass Index and body composition. Obesity Research 4(1), 35– 44. Whitlock, E.P., Williams, S.B., Gold, R., Smith, P.R., & Shipman, S.A. (2005) Screening and interventions for childhood overweight: a summary of evidence for the US Preventive Services Task Force. Pediatrics 116(1), e125–e144. WHO Expert Committee (1995) Physical status: the use and interpretation of anthropometry. Geneva: World Health Organization. World Health Organization (2006) WHO child growth standards: length/height-for-age, weightfor-age, weight-for-length, weight-for-height and body mass index-for-age: methods and development. Geneva: World Health Organization. World Health Organization (2008) WHO child growth standards: training course on child growth assessment. Geneva: World Health Organization. Williams, S. (2000) Body Mass Index reference curves derived from a New Zealand birth cohort. New Zealand Medical Journal 113(1114), 308–311. Willows, N.D., Johnson, M.S., & Ball, G.D. (2007) Prevalence estimates of overweight and obesity in Cree preschool children in northern Quebec according to international and US reference criteria. American Journal of Public Health 97(2), 311–316.

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Yngve, A., De, B. I., Wolf, A., et al. (2008) Differences in prevalence of overweight and stunting in 11-year olds across Europe: the pro children study. European Journal of Public Health 18(2), 126–130. Young, M.E., Norman, G.R., & Humphreys, K.R. (2008) The role of medical language in changing public perceptions of illness. PLoS.ONE 3(12), e3875. Zimmermann, M.B., Gubeli, C., Puntener, C., & Molinari, L. (2004) Detection of overweight and obesity in a national sample of 6–12-y-old Swiss children: accuracy and validity of reference values for body mass index from the US Centers for Disease Control and Prevention and the International Obesity Task Force. American Journal of Clinical Nutrition 79(5), 838–843. Disclaimer: The findings and conclusions in this report are those of the authors and not necessarily those of the Centers for Disease Control and Prevention.  This is an updated and revised version of a previous publication: Flegal, K.M., Tabak, C.J., & Ogden, C.L. Overweight in children: definitions and interpretation. Health Education Research 2006 Dec 21(6):755–760.

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Stigma and BMI screening in schools, or ‘Mom, I hate it when they weigh me’

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Stigma and BMI screening in schools, or ‘Mom, I hate it when they weigh me’ Lynne M. MacLean Mechthild Meyer Audrey Walsh Kathryn Clinton Lisa Ashley Stephanie Donovan Nancy Edwards

DOI:10.1093/acprof:oso/9780199572915.003.0002

Abstract and Keywords ‘Mom, I hate it when they weigh me’. These words were uttered by a child of one of the authors of this chapter. This quote was chosen as the title of this chapter on stigma and BMI screening in schools since it captured some of the experience of children made to feel different in a public setting because of their weight. School is a particularly important public setting, full of children striving for acceptance by their peers, as well as themselves, hoping perhaps to stand out in terms of achievement but not in terms of characteristics that will lead to ridicule and isolation. What role, if any, might Body Mass Index (BMI) screening in schools play in increasing stigmatization of the overweight/obese? Are there solid reasons justifying BMI screening in schools? Might other approaches provide us with the same information? This chapter explores some of these issues and offers some alternative paths for dealing with weight issues in the school setting.

Keywords: BMI, stigma, screening, schools, measurement, weight, overweight, obesity, children

Chapter summary ‘Mom, I hate it when they weigh me’. These words were uttered by a child of one of the authors. We chose the quote as the title of this chapter on stigma and BMI screening in schools as it captured some of the experiences of children who are made to feel different in a public setting

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because of their weight. School is a particularly important public setting, full of children striving for acceptance by their peers, as well as themselves, hoping perhaps to stand out in terms of achievement but not in terms of characteristics that will lead to ridicule and isolation. What role, if any, might Body Mass Index (BMI) screening in schools play in increasing stigmatization of the overweight/obese? Are there solid reasons justifying BMI screening in schools? Might other approaches provide us with the same information? This chapter explores some of these issues and offers some alternative paths for dealing with weight issues in the school setting.

Introduction In many industrialized countries, concerns have been raised about increasingly high rates of obesity and overweight. Worldwide, obesity among school-aged children is reported to be highest in the Americas, followed by the Near/Middle East and Europe (Berghöfer et al., 2008). Rates are reported to have exceeded predicted trajectories (International Obesity Task Force, 2004). Health and education sectors and the popular media have become highly sensitized to the issue. Calls to action are many (Brownell, 2005; Saguy & Riley, 2005) but may inadvertently do more harm than good in dealing with an already stigmatized condition. Given the potentially large numbers of children affected, we need to examine the need for any screening approaches which might lead to further stigmatization of overweight/obese children. What is BMI and how is it used? Although BMI can be used for both screening and surveillance purposes, in the school setting it is more commonly used as a surveillance tool. According to Nihiser et al. (2007) school-based BMI measurement for surveillance is more widely acceptable than BMI measurement for screening purposes, which provides parents with personalized health information about their child’s weight status and pursuant guidelines for action, in effect, a ‘BMI report card’. While controversy surrounds the use of BMI for both purposes, there is greater concern surrounding the report cards. This is because of their greater potential for stigmatizing children through the impact of direct measurement in a school environment combined with the possible effects of labeling from the school, health professionals, peers, and self-labeling. (p.18) What is stigma and how does it relate to obesity? People develop negative stereotypes of groups of others, and the process of stigmatization links individuals with these negative stereotypes. The stigma leads others to see them as tainted or shameful (Goffman, 1963). Stigmatized groups are marginalized, and the stigmatized condition is typically associated with other forms of marginalization such as poverty, disability, racial or cultural discrimination, leading to layering of stigmas, with potentially compounding impacts from each source of stigma (Mill et al., 2007; Reidpath & Chan, 2005). Overweight or obese children who come from other marginalized groups may experience layers of stigma, such as ethnic discrimination (Mill et al., 2007; Reidpath & Chan, 2005), and be especially susceptible to the effects of stigma. This is a particular concern given the different histories, including colonialization impacts, that minority groups have with the mainstream health and education systems; the trust or lack of trust of people in positions of authority; and the cultural competency and accessibility of education and health services. From both the external impositions of discrimination, and from living with the constant stress of expecting hostile reactions from others (perceived stigma), stigmatized people suffer chronic

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stress, low self-esteem and internalized oppression, constricted social networks, depression, unemployment or under employment, and poor health outcomes (Green, 1995; MacLean et al., 2009; Stuber et al., 2008). Research suggests there is an interaction between the psychological (stress-related/social exclusion) factors resulting from stigma and the physical/physiological consequences of obesity. Indeed, the poor health outcomes from stigma are those that are often attributed solely to the physical consequences of obesity: depression, hypertension, coronary heart disease, and stroke (Major & O’Brien, 2005; Stuber et al., 2008). The stigmatization of the obese has been documented for a very long time. In 2001, Puhl and Brownell reviewed four decades of research on weight-based discrimination. In Puhl and Heuer’s (2009) more recent review, now covering the literature since 2000, they note that stigmatization of the obese remains prevalent, and has worsened. They report that, especially among women, it is now comparable to rates of racial discrimination as well as being reported as more hurtful by those who experience both. The stereotype

In Western countries, overweight/obesity has traditionally been considered an indication of laziness and poor impulse control (O’Brien et al., 2007; Puhl & Heuer, 2009). Along with lack of personal responsibility, the obese have been stereotyped as being less intelligent, emotionally unhealthy, and socially inept (O’Brien et al., 2007; Puhl & Heuer, 2009). The preponderance of research evidence disputes these stereotypes, but they are still perpetuated and held by people in all walks of life, including health care providers, education professionals (O’Brien et al., 2007; Puhl & Heuer, 2009), and the obese themselves. There are misunderstandings, even among health care professionals, about the actual causes, effects, and treatment efficacies for obesity (Downey 2005; Fabricatore et al., 2005; Friedman, 2004; Szwarc, 2004–2005; Vaidya, 2006), including the lack of awareness that on average, active obese people are healthier than inactive non-overweight people, and the profound and intransigent impact of genetics on obesity (Szwarc, 2004–2005). Impacts of stigma

The results of stigma include obese people experiencing, on a regular basis, derogatory remarks (Puhl & Heuer, 2009), avoidance by others (Latner & Schwartz, 2005), discriminatory hiring practices (Stuber et al., 2008), ‘humour’ (Brownell, 2005), and denigration in many media channels (Puhl & Latner, 2009). This translates into inequities in employment, health care, education, and interpersonal relations (Puhl & Latner, 2007). Stigma can also impact self-esteem and emotional (p.19) and physical health. It leaves obese people vulnerable to reduced quality of life and is arguably a form of social injustice. Children and teenagers are just as much affected by these effects of stigma as adults, indeed, perhaps more so. Obesity is also positively correlated with poverty in much of the world (Commission of the European Communities, 2007; Lamerz et al., 2005; Puhl & Latner, 2007). Children from lower socio-economic status (SES) groups are already stigmatized, and feel that they and their families are marginalized, not part of society (Robinson et al., 2005; Stewart et al., 2005).

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Pathways for stigma in surveillance, screening, and report cards

Thus far, we have considered how obesity is stigmatized. We will now discuss how a seemingly innocuous procedure, screening children for obesity in schools, may also induce stigma. Hopefully, in most cases screening is carried out in the school setting in a sensitive and respectful manner, acknowledging the potential for stigmatization and according to recommended best practices (e.g., United Kingdom Department of Health, 2009), such as: measurements being taken in private; use of trained health/education professionals; use of accurate measurement tools and procedures; results sent home through the mail, not in the child’s backpack; and provision of supportive, neutral advice and follow-up. If so, then the question arises: how would it be possible for stigmatization to occur? 1 Through felt or perceived stigma, which is likely to be heightened through sensitivity to being weighed. 2 Through parents' attitudes and behaviours upon receiving the report card, if their child is classified as overweight or obese and the family has not previously labeled them as such. Although one hopes that parents use this as an opportunity for improving healthy lifestyles and nutrition, that may not always be the case. Parents holding negative stereotypes of obese people pass these along to their obese children, even if the parents are obese, through teasing, critical and negative comments, focus on weight and body size, and even, reduced financial support (Puhl & Latner, 2007). 3 Through behaviours and attitudes communicated by those doing the measuring (Ikeda et al., 2006). Ideally, measures are taken by a health professional, but sometimes they train and supervise others carrying out the process (United Kingdom Department of Health, 2009). Given this era of limited health and educational resources, it would not be impossible to find educators conducting the measures (Ikeda et al., 2006). Teachers in general have been found to hold stigmatizing attitudes towards obese students. Weight bias among teachers may affect students’ academic achievements in elementary school, and this dynamic continues through to college (Puhl & Heuer, 2009; Puhl & Latner, 2007). Yager and O’Dea (2008) found that health and physical education student teachers were more likely to suffer from poorer body image, and higher levels of body dissatisfaction, disordered eating, dieting, and exercise disorders than other student teachers. This, coupled with the findings of O’Brien, Hunter, and Banks (2007), of the comparatively high levels of anti-fat bias among physical education teacher trainees, and the fact that these levels increase the longer trainees had studied in the programme, makes one cautious about offering any further opportunities for teachers to share these weight-related attitudes with children. These attitudes would be particularly problematic if teachers were conducting the measurement as students have ongoing daily contact with them. But, using school staff departs from best practices. Health professionals, however, are also not immune from communicating stigmatizing attitudes to obese children. The sometimes biased, sometimes misinformed behaviours of health care professionals and the health care system that impact on adults (MacLean et al., 2009; Puhl & Heuer, 2009; Puhl & Latner, 2007) can also affect children. (p.20) 4 Through a general increase of salience of weight as an issue and weigh-ins as an event and an opportunity for teasing in the school environment even if measurement is

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conducted in private. (‘I think that if there are rude children who think it’s funny to tease someone about their weight then being weighed in school is a perfect opportunity’. Quote from child in Grimmett et al., 2008 p.688). In the school setting, children are vulnerable to the prejudices of peers and educators. The impact of peers can be powerful. Children consider obese peers to be the least desirable among undesirable types of playmates, even if they themselves are overweight or obese (Puhl & Latner, 2007). This stigma has been systematically observed in preschoolers as young as 3-yearolds, and throughout the age continuum. Children have been asked, in a variety of studies since the 1960s, to choose and rank playmates from among pictures and stories of various kinds of positive, neutral, negative, and stigmatized kinds of children. Obese children end up consistently being ranked last, even by other obese children (Latner & Schwartz, 2005; Puhl & Heuer, 2009). Obese children are often targets for teasing, bullying, and other forms of victimization (Latner & Schwartz, 2005). Obese children and adolescents face stigmatizing attitudes from the health system, their peers, educators, and parents (Puhl & Latner, 2007). If the school is to be considered as a setting for any activities focusing on weight issues, caution must be asserted. Even the attempts by health and education professionals to help may end up unintentionally creating body image problems and disordered eating when focusing child obesity prevention programmes on overweight and weight control (O’Dea, 2004) rather than more universally targeted healthy living programmes (MacLean et al., 2009). Indeed, the United States’ National Education Association’s 1994 report on size discrimination concludes that ‘the school setting is a venue for ongoing ostracism, stigmatization, and discrimination for overweight and obese youths from nursery school through college’ (Puhl & Latner, 2007, p. 563). Where does BMI screening occur?

BMI measurement in schools is found in many places in the world, and has been used, for example, for screening in Australia, Canada, Europe, the United Kingdom, and the United States (Grimett et al., 2008; Guilliatt, 2009; Nihiser et al., 2007; Vaska & Volkmer, 2004). The approach to using BMI varies widely, in terms of policy level (national, state, provincial, and/or regional), purpose (surveillance or screening), and requirement of participation in measurement and/or receiving report cards (mandatory vs. opt in/opt out). Some communities have expressed resistance to this activity or to the policy supporting it (Demerath et al., 2003; Ikeda et al., 2006; Nihiser et al., 2007). Screening at school is conducted with children at various ages, ranging from kindergarten to middle school, depending on the programme. The Canadian situation: BMI screening and alternative monitoring trends in Canada We will now focus on activities in our own country as a case example, to provide a snap-shot of one country’s experience with BMI use and alternate screening approaches. Canadian surveillance

In Canada, in terms of surveillance, national and school-based surveys capture self-reported data (height and weight) to calculate BMI (see Table 2.1).

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One survey does not use BMI, but rather activity levels, when trying to assess child health (CAN PLAY, Canadian Fitness and Lifestyle Research Institute, 2008) and these are both measured and self-reported. Data are typically aggregated at health region levels or higher. (p.21)

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Table 2.1 A snapshot of Canadian monitoring approaches Survey/ instrument

BMI (or other)

Measurement procedure (all voluntary)

Age group

Survey administration

Focus for change

Population reach

WHO – Health Behaviour in School-Aged Children Study (Boyce 2004; Janssen et al., 2004)

Height/ weight

Self report

11–16

Schools

National and international levels

International (+ Canada)

Canadian Community Health Survey (annually collected) (Tjepkema & Shields, 2005)

Height/ weight

Self report

12 and over

Telephone

Health region level

Canada

National Longitudinal Survey of Children and Youth (bi-annual) (Willms et al., 2003)

Height/ weight

Parent (if 0-17) Youth self-report (if 18–23)

0–23

Telephone

National & provincial levels

Canada

The School Health Action Planning Height/ weight and Evaluation System (SHAPES, 2006)

Self-report

Mostly 11–18

School

School profiles & individual student profiles

Schools; Canada-wide

CAN PLAY (Canadian fitness survey) (Canadian Fitness and Lifestyle Research Institute, 2008)

Steps taken pedometer

Parent; child 7-day use of pedometer

5–17

Home, written National, provincial, Canada survey, pedometer and territorial levels data

NutriSTEP – Canadian Nutrition Screening (NutriSTEP, 2009)

Nutrition screening

Parent

3–5

Home, written questionnaire

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Individual child/ family

School & public health, Canadawide

Stigma and BMI screening in schools, or ‘Mom, I hate it when they weigh me’

(p.22) Some of the instruments mentioned here are used in programmes focused on change at the school level, and monitoring the success of school system initiatives. For example, the School Health Action, Planning and Evaluation System (SHAPES), now fairly widely implemented in secondary schools in Ontario, gathers height and weight information in order to determine BMI (Health Behaviour Research Group and the Centre for Behavioural Research and Program Evaluation of University of Waterloo and University of Manitoba, 2004). However, individual reports are available should the participants wish. Similarly, other well-known, school-based interventions including the Annapolis Valley Health Promoting Schools Program (Veugelers & Fitzgerald, 2005), the Child and Adolescent Trial for Cardiovascular Health (CATCH) (Luepker et al., 1998); Planet Health (Gortmaker et al., 1999); and the Keil Obesity Prevention Study (KOPS) (Muller et al., 2001) include BMI measurements in their outcome variables. Canadian screening and report cards

There appear to be no standards or requirements or provincial guidelines for BMI screening in schools for any of the Canadian provinces. However, BMI is used widely to determine overweight/obese children and youth in the health system, and is often recommended for screening in clinical and community settings (Dietitians of Canada, 2004a, 2004b, p. 172). There is variation, however, in the degree to which self-report data are used, and when actual individualized reports are provided. Ways to measure BMI in Canada: pros and cons

Some users of Canadian school programmes for healthy living use self-report for calculation of BMI rather than on-site measurement. In an email communication, September 28, 2009, S. Manske, Scientist for the Centre for Behavioural Research and Program Evaluation (CBRPE) and Research Associate Professor in Health Studies and Gerontology, in the faculty of Applied Health Sciences at the University of Waterloo and a senior scientist for SHAPES, reported that SHAPES is implemented in all provinces, but height and weight data have only been collected in Ontario, Alberta, British Columbia, Prince Edward Island, and New Brunswick. Eighty percent of the time these data are self-reported, included in the Physical Activity and Healthy Eating Module of the survey. Self-report can have its difficulties. For example, younger students (grades 6 and 7, ages 10–12 years) often don’t report one or other of height and weight, possibly because they don’t know the answer, or because they don’t want to answer the question. When students are weighed, careful explanation of protocols often removes parental and student concerns. Still, many school boards and individuals will not participate due to the collection of physical measurements. This occurred with a SHAPES study called PLAY – Ontario. However, in general, self-reported height and weight questions do not seem to generate controversy or resistance, and seem acceptable to participants, although there are problems at school board, school and individual levels with collecting physical measurements, at least in one Ontario study. A different approach has been taken by one Canadian nutrition screening programme. NutriSTEP is a comprehensive nutritional screening tool that aims to identify potential nutritional problems in preschool children, and provide referrals to community health services and follow-up for those who are at high risk. It was developed to provide a validated, general

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nutrition screen that could be used by parents at home. The questionnaire does not ask parents to report height and weight measurements, but rather asks parents if they are comfortable with the way their child is growing in terms of weight (NutriSTEP, 2009; Randall Simpson & Keller, 2008). Although some of the public health and school programmes that use NutriSTEP follow up this broad nutritional screen with assessments that include measurement of BMI, not all do. NutriSTEP supports BMI measurement after screening. Given that nutritional assessment is ‘a subjective, rather than an (p.23) objective process’ (Randall Simpson et al., 2008, p. 776), it is broad based, covering a number of constructs, not just height and weight. What is more, it is centred on the parent’s concern, rather than sending a label home to parents and children. Report cards – Useful? Benign? Harmful? Acceptable? A small number of studies have actually tested the use of report cards and the reactions of families to them. Findings are mixed. On the positive side, in a US study, Chomitz et al. (2003) (from Ikeda et al., 2006) report that about 50% of parents of children reported in a BMI report card as being overweight wanted to make changes in their children’s weight. They did not tend to make changes in lifestyle behaviours but rather diet-based weight-control strategies (generally contra-indicated), and 40% were not planning to seek medical advice. Sadly, a small number of parents of children not categorized as overweight also reported plans to restrict diet. Grimmett et al. (2009), in an opt-in BMI report card study in the UK found generally positive results from those families taking part, in terms of acceptability and changes in child selfesteem. However, the self-selection of families into this programme limits the findings. Fortynine percent of parents originally contacted chose not to participate, including some with quite vociferous objections and their sample was unrepresentative, having lower rates than the national average of overweight, obese, low SES, and minority children. In addition, of those who did take part, 35% did not wish to take part in further weighing in the future. Thus, ultimately only 33% of parents from the schools involved could reasonably be said to be in favour of such activities in the future. This suggests that choices were being made about this process by those potentially most affected by the problem of weight issues, including issues of stigma. Similar problems in terms of participation and acceptability of the process have occurred in other studies. Demerath et al. (2003) had an opt-out rate of 60% of families choosing not to participate. Once such opt-in school screening programmes enter the realm of legislation, Demerath et al. (2003) point out that key issues of roles of parental consent, child assent, confidentiality, privacy, and ethical and legal issues emerge. Thus, the jury appears to be out on the actual benefits of school-based screening versus the concerns about and potential for stigmatization of children. There do seem to be sufficient ongoing concerns to make many families choose not to participate, thus limiting the usefulness of findings. A number of controversies continue to surround it and its role in helping children to live healthier lives. Controversies Measuring and reporting versus labeling: Is BMI a good measure?

Concerns continue to surround the use of BMI as a measure of overweight and obesity, particularly with children. To determine whether a child with a high BMI has excess fat, further assessment is needed such as triceps skin fold thickness measurements, comorbidity, family history, and recent health history (Centers for Disease Control and Prevention, 2009). The

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Canadian Pediatric Society (2004) recommends that BMI recordings should be used as guidance for further assessment, referral, or treatment, rather than as a diagnostic criterion for labeling children. Downey (2005) suggests that the use of this measure has led to general confusion about the ‘obesity epidemic’. Some literature contends that mislabeling often occurs. In one study, one-fourth of clinically evaluated children with normal levels of body fat were mislabled as being at risk for obesity (Szwarc, 2004–2005). There has been some controversy about using BMI as a measure across population groups especially for children and teens, given that adolescents develop and mature at different ages (Nonnemaker et al., 2009; Sellers et al., 2008). These authors question its reliability as a standard for comparison purposes. In addition, children normally shift in major BMI percentiles up and (p.24) down the growth curves over the course of growing, that only about 30% of the children at the 95th weight percentile when younger are in the higher percentiles when older, and that ‘most children will unnecessarily and prematurely be labeled fat’ (Szwarc 2004–2005, p.98). BMI surveillance: how do we know if the obesity epidemic is getting better or worse? How do we not measure?

It is an ethical mandate to know what is happening to children, when they are at risk or when their health is improving or worsening (Institute of Medicine IOM, 2004) at both population and individual levels. Adhering to this mandate, the rise in obesity rates among children and the subsequent risk of potentially developing chronic illness secondary to obesity would suggest that there is an ethical obligation to weigh and measure children to monitor this health problem. Measurements would be needed to provide bench marks against which to judge whether childhood obesity rates are improving or specific interventions are working. Few would suggest that this health problem does not need to be monitored, especially considering recent concerns over misinterpretation of obesity-related statistics, including the BMI (Downey, 2005; Guilliatt, 2009; Strawbridge et al., 2000). However, controversy exists regarding how and where this measuring occurs. Although surveillance involving on-site measurement does have fewer of the components that could cause stigma (reporting to the child’s parents, child awareness of their label), it does involve the first steps of weighing in at school in an environment now sensitized to the issue. These concerns lead school boards to choose not to participate in school-based surveillance activities such as the PLAY Ontario programme described previously. In light of this, it might appear that self-report national surveys are a better way to monitor the child obesity problem, rather than using on-site measurements obtained from individuals. How can we help kids if we don’t screen them?

Proponents of BMI screening and report cards would suggest that it is a non-invasive, inexpensive procedure that, if carried out properly, will not lead to undue stress or stigma, and should lead to more informed parents, healthier lifestyles, and health system follow-up. This would be particularly critical for low SES students with little access to universal health care (such as in the United States), in communities with high rates of obesity, whose families may not have identified them as overweight (Demerath et al., 2003). Screening, however, is not, in itself, automatically benign, for any health issue. When commenting on screening in primary health care settings, the US Preventative Services Task

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Force (USPSTF) found insufficient evidence to recommend for or against formal screening of children and adolescents for overweight and obesity. One of the noted problems in this recommendation is the lack of evidence regarding the potential harms of screening to children and their families, such as labeling, disordered eating, diminished self-esteem, poor health habits, and adverse impact from parental concerns (Whitlock et al., 2005). In a collaborative statement, the Dieticians of Canada, the Canadian Pediatric Society, the College of Family Physicians of Canada, and the Community Health Nurses Association of Canada weigh in on this issue as well, suggesting that any practices that suggest blame or cause feelings of guilt or shame, or any practices that focus on physical appearance rather than healthy eating and lifestyle habits, have the potential to cause harm and should be avoided (Dietitians of Canada, 2004). What about after the screening?

Whenever screening is carried out for any health-related reason it is important to remember that screening tests are not diagnostic tests. Screening of any kind carries an ethical commitment to continue working with individuals with positive or questionable screening results to provide (p.25) them with access to adequate, effective, and assessable methods of diagnosis and early treatment (Shah, 2003). Is it helpful, indeed even appropriate, to carry out screening in the absence of adequate, effective, and assessable methods of diagnosis and early treatment? In 2005 the United States Centers for Disease Control and Prevention (CDC) convened an expert panel to develop guidance for Body Mass Index (BMI) measurement programmes within schools. An article to inform decision makers was produced (Nihiser et al., 2007). Based on available information and citing a number of sources, Nihiser et al. (2007) conclude that BMI screening does meet several but not all of the screening criteria established by the AAP for determining whether schoolbased screening should be implemented for specific pediatric health conditions. In particular, AAP criteria for school-based BMI screening programmes are not met in that the efficacy and cost effectiveness of BMI screening programmes have not been well established by research, proven treatments for childhood and adolescent obesity are not widely available, and many communities do not have the necessary resources in place to help at-risk children and youth access treatment services. It would appear that there is a potential for causing unintentional harm when carrying out BMI screening programmes in schools. Rather than wasting valuable human and financial resources to measure children in schools it might be a better approach to encourage and support healthy life style approaches for all individuals, families, and communities, and making environmental changes. Instead of taking a blaming and stigmatizing approach where the individual is targeted, Cogan, Smith and Maine (2008) suggest shifting the paradigm of how we approach obesity and health by redirecting our focus on the bigger picture recognizing the many systemic factors that come together to create the problem. Do we weigh kids or feed them? Will BMI report cards bring access to healthy foods?

Weighing children for screening or surveillance purposes identifies the outcomes (obesity) that may be the result of underlying issues (e.g. genetic predisposition to obesity, lack of affordable fruits and vegetables, lack of time to prepare meals). But it does not identify these underlying

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issues and thus fails to help schools with answers to questions like should we provide a feeding programme for children who don’t get breakfast at home, should we allow children to share their lunches and should we have vending machines? These are practical programming concerns of great interest to educators who are trying to create optimal conditions for learning. These concerns are particularly challenging for schools that are resource-strapped and situated in lowincome areas. It is in these schools that the teachers see the day-to-day impact of poor nutrition on children’s ability to learn. It is in these schools where children are living in neighbourhoods that are ‘food deserts’ (Wrigley et al., 2003), and where children are eating more ‘junk’ food because on a calorie-for-calorie basis this is a more economical food choice or where children are coming to school hungry because families are having to resort to a packaged, dry macaroni and powdered cheese sauce made without milk to fill tummies (Rock et al., 2008). Economic inequality may be an even more significant social determinant of health than absolute poverty. As the gap between rich and poor widens, health status declines (Auger et al., 2004; Raphael, 2002). There has been a growing recognition of the need for programmes promoting nutrition, in part through the provision of things like breakfast programmes. School systems are having a harder time in meeting the needs of their children. The public school systems, in Canada, for example, have been under stress in recent years due to budget cutbacks, labour conflicts, and pressure to address increased needs such as special education. Canada’s child poverty rate is higher than many similarly developed countries. Food security is also a critical issue, with the prevalence of and need for school food programmes and food banks on the rise (Ungerleider & Burns, 2004). (p.26) Low SES could be a determinant of obesity through mechanisms such as food insecurity, parental education, and lack of safe, affordable, and accessible environments, and events for physical activity (Currie et al., 2004; Lamerz et.al., 2005; MacLean et al., 2009). In Doak et al.’s 2006 review, a wide array of multi-level factors have an impact on the prevalence of overweight/ obesity including the economy, and the price and availability of food. Given limited school resources, school systems may have to choose between using resources for ensuring accurate BMI screening training, equipment, personnel, referral mechanisms and administration, or for interventions such as breakfast programmes and exercise activities that may improve health for all children, including overweight and obese children. Tearing down the vending machines versus BMI screening

If schools and their public health partners make commitments to improving child health and reducing obesity, then not only will they have to make decisions about what to spend money on, but also on what sources of revenue they are willing to give up. For example, vending machines are often used to generate income for schools through corporate partnerships. Vending machines often sell unhealthy food or drink items that contribute to obesity. ‘We will buy better physical education equipment from the money we get from the vending machine profits’. These or similar arguments are not uncommon among proponents for keeping vending machines in schools, where students often access them after school cafeterias (with their healthier offerings) are closed for the day (Estable et al., 2007). Schools may need to consider what has a greater impact on reducing obesity, using resources for surveillance of weight or for surveillance of vending machines? And then, if the machines are no longer used and bring in revenue, does BMI

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screening, with its unclear and inconsistent efficacy, as well as its potential for stigmatizing, seem like a useful choice for using even more limited resources? Alternatives to measuring BMI: Let’s look at the whole system Perhaps it is time to consider other approaches to measuring the success of initiatives leading to healthier living for all children? This would include initiatives working towards changing the broader system (active environment, food security) using less stigmatizing and likely more effective approaches than ones that focus on the individual. Given that individually focused interventions for child obesity show very little long-term efficacy upon follow-up (Puhl & Brownell, 2003; Szwarc, 2004–2005), that there may be too much emphasis already on weight, diet, and food intake in Western societies, requiring a culture shift to normalize food intake and reduce the preoccupation with weight, dieting, and body images (Carlson Jones et al., 2004); that being overweight does not necessarily mean being unhealthy (Szwarc, 2004–2005), and that children of all sizes in Western countries are less active (Wang et al., 2009), it appears that most of the promise for future obesity work lies with prevention and the larger, systemic environments (Alderman et al., 2007; MacLean et al., 2009; Maziekas et al., 2003; Schwartz & Brownell, 2007). Instead of measuring students’ individual BMI, other indicators to assess healthy school environment could be developed. These indicators might include monitoring: student access to healthy food throughout the school day and after school; number of students participating in extra curricular sport activities; students’ average hours of participation in physical activity; level of diversity and types of activities offered (e.g., not only highly competitive programmes; team versus individually oriented sports; outdoor, indoor); number of trained physical education teachers per student; student satisfaction with access to healthy food; student satisfaction with access to physical education and to extra curricular activities. Perhaps instead of screening students, possibilities exist for screening at different system levels – perhaps screening schools, not children, for risk of low activity, such as measuring the amount of (p.27) playground space available for free play? Again, the concerns and criteria involved with stigma and any screening would have to be considered to protect schools from being labeled. Other approaches and indicators to monitor population health exist, e.g., fitness levels, hours of daily physical activity, or sedentary behaviour. Alternative and more macro approaches to measuring population health might include examining the extent to which governments regulate the food, diet, and fitness industry. The greatest impact on a population likely will be the regulation of the fast food and food production industry. Denmark and Canada were the first nations to ban trans fats, with the result that in Denmark trans fat intake dropped from 6 grams in 1976 to 1–2 grams of daily intake in 2005 (Deitel, 2005). Again, this form of public health policy must be enacted in ways that do not inadvertently lead to stigmatization of the poor and overweight (MacLean et al., 2009). Environmental assessments include the extent to which neighbourhoods are conducive to walking, biking, and to increasing physical activity, as well as lowering access barriers for participation in fitness programmes. For example, a study found that walking distance to

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shopping was a predictor for being less likely to be obese (Frank et al., 2004). Finally, given that children from lower socioeconomic backgrounds overall show the highest proportions of overweight and obese children, addressing the social determinants of health and health inequities might have the greatest impact overall.

Conclusions Given the lack of clear support for BMI itself, the mixed results of its use in schools for screening report cards, the possibilities of using other indicators of healthy living, and its potential for stigma, the use of BMI screening in schools must be carefully considered. As Puhl and Latner (2007, p.576) suggest: ‘The problem is a societal one, and broader, population-level efforts at reducing stigma are needed. Weight-based discrimination is as important a problem as racial discrimination or discrimination against children with physical disabilities. Remedying it needs to be taken equally seriously, if we are to protect the emotional and physical well-being of our nation’s children’. Assuming the reported worldwide trends are accurate, a huge number of stigmatized children need support and consideration. If the trends are not accurate, as some contend (e.g. Downey, 2005; Guilliatt, 2009; Strawbridge et al., 2000), we need to seriously question measuring BMI and screening in schools and placing any more children into an unnecessarily stigmatized position. References Bibliography references: Alderman, J., Smith, J.A., Fried, E.J., & Daynard, R.A. (2007) Application of the law to the childhood obesity epidemic. The Journal of Law, Medicine, & Ethics 35(1), 90–112. Auger, N., Raynault, M.F., Lessard, R., & Choinière, R. (2004) Income and health in Canada. In D. Raphael (Ed.), Social determinants of health. Toronto: Canadian Scholars’ Press Inc. Berghöfer, A., Pischon, T., Reinhold, T., Apovian, C.M., Sharma, A.M., & Willich, S.N. (2008) Obesity prevalence from a European perspective: a systematic review. BioMed Central Public Health 8(200), 1–10. Brownell, K.D. (2005) The chronicling of obesity: growing awareness of its social, economic, and political contexts. Journal of Health Politics, Policy and Law 30, 955–964. Boyce, W.F. (2004) Young people in Canada: Their health and well-being 2001-2002 survey. HBSC: Health Behaviour in School-aged Children, A World Health Organization cross-national study (No. Cat. no. H39-498/2004E). Ottawa, ON: Health Canada. Canadian Fitness and Lifestyle Research Institute (2008) Kids CAN PLAY, Bulletin 1. Retrieved on September 30, 2009 from Carlson Jones, D., Vigfusdottir, V.H., & Lee, Y. (2004) Conversations, peer criticism, appearance magazines, and the internalization of appearance ideals body image and the appearance culture among adolescent girls and boys: an examination of friend. Journal of Adolescent Research 19, 323.

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Centers for Disease Control and Prevention (2009) CDC/National Center for Health Statistics, Atlanta, GA, viewed 23 June 2009, . Chomitz, V., Collins, J., Kim, J., et al. (2003) Promoting healthy weight among elementary school children via a health report card approach. Archives of Pediatrics & Adolescent Medicine 57, 765–772. Cogan, J.C., Smith, J.P., & Maine, M.D. (2008) The Risks of a Quick Fix: A Case Against Mandatory Body Mass Index Reporting Laws. Eating Disorders 16, 2–13. Commission of the European Communities (2007) White Paper on a Strategy for Europe on Nutrition, Overweight and Obesity Related Health Issues. Brussels. Currie, C., Roberts, C., Morgan, A., et al. (eds), (2004) Young people’s health in context: Health Behaviour in School-aged Children (HBSC) study: international report from the 2001/2002 survey. World Health Organization: Health Policy for Children and Adolescents, No. 4. Deitel, M. (2005) Editorial. Mounting the worldwide effort against obesity. Obesity Surgery 15, 595–597. Demerath, E., Muratova, V., Spangler, E., Li, J., Evans Minor, V., & Neal, W. (2003) Schoolbased obesity screening in rural Appalachia. Preventive Medicine 37, 553–560. Dietitians of Canada (2004a) The use of growth charts for assessing and monitoring growth in Canadian infants and children. A collaborative statement from Dietitians of Canada, Canadian Paediatric Society, The College of Family Physicians of Canada, and Community Health Nurses Association. [Electronic Version]. Canadian Journal of Dietetic Practice and Research 65, 29–32. Retrieved June 13, 2005 from . Dietitians of Canada (2004b). The use of growth charts for assessing and monitoring growth in Canadian infants and children. Executive summary. Doak, C.M., Visscher, T.L.S., Renders, C.M., & Seidell, J.C. (2006) The prevention of overweight and obesity in children and adolescents: a review of interventions and programmes. Obesity Reviews 7(1), 111–136. Downey, M. (2005) Expression of bias against obesity in public policy and its remedies. In K. Brownell, R.M. Puhl, M.B. Schwartz, & L. Rudd (Ed.), Weight Bias: Nature, Consequences, and Remedies. New York: The Guildford Press. Estable, A., Meyer, M., & Murkin, E. (2007) Improving nutrition through healthier vending machines? Student insights, presented at the Canadian Public Health Association Annual Conference, Ottawa, 16–19 September, 2007. Fabricatore, A.N., Wadden, T.A., & Foster, G.D. (2005) Bias in health care settings. In K.D. Brownell,R.M. Puhl, M.B. Schwartz, & L. Rudd (Ed.), Weight bias: nature, consequences, and remedies. London: The Guildford Press.

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Frank, L.D., Andresen, M.A., & Schmid, T.L. (2004) Obesity relationships with community design, physical activity, and time spent in cars. American Journal of Preventative Medicine 27(2), 87–96. Friedman, J.M. (2004) Modern science versus the stigma of obesity. Nature Medicine 10, 563– 569. Goffman, E. (1963) Stigma: notes on the management of spoiled identity, Simon and Schuster, New York. Gortmaker, S.L., Peterson, K., Wiecha, J., et al. (1999) Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Archives of Pediatric & Adolescent Medicine 153(4), 409–418. Green, G. (1995) Attitudes towards people with HIV: are they as stigmatizing as people with HIV perceive them to be? Social Science and Medicine 41(4), 557–568. Grimmett, C., Croker, H., Carnell, S., & Wardle, J. (2008) Telling parents their child’s weight status: psychological impact of a weight-screening program. Pediatrics 122(3), e682–e688. Guilliatt, R. (2009) Off the scale. Weekend Australian Magazine 9–10 May, pp.18–24. Health Behaviour Research Group and the Centre for Behavioural Research and Program Evaluation of University of Waterloo and University of Manitoba (2004). SHAPES: School Health Action, Planning and Evaluation System. Physical Activity Module, AnyPlace Secondary School. Waterloo, ON: University of Waterloo. Ikeda, J.P., Crawford, P.B., & Woodward-Lopez, G. (2006) BMI screening in schools: helpful or harmful. Health Education Research 21(6), 761–769. Institute of Medicine (2004) Children’s health, the nation’s wealth: assessing and improving child health. Washington DC: National Academies Press. International Obesity Task Force (2004) Obesity in children and young people, a crisis in public health. . Contact: [email protected]. Janssen, P.T., Katzmarzyk, W.F., Boyce, C., et al. (2004) Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationships with physical activity and dietary patterns. Obesity Reviews 6(2), 123–132. Lamerz, A., Kuepper-Nybelen, J., Wehle, C., et al. (2005) Social class, parental education, and obesity prevalence in a study of six-year-old children in Germany. International Journal of Obesity 29(4), 373–380. Latner, J.D. & Schwartz, M.B. (2005) Weight bias in a child’s world. In K.D. Brownell, R.M. Puhl, M.B. Schwartz, & L. Rudd (Ed.) Weight bias: nature, consequences, and remedies, pp. 54–67. London: The Guildford Press.

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Luepker, R.V., Perry, C.L., Osganian, V., et al. (1998) The Child and Adolescent Trial for Cardiovascular Health (CATCH). Journal of Nutritional Biochemistry 9, 525–534. MacLean, L., Edwards, N., Garrard, M., Sims-Jones, N., Clinton, K., & Ashley, L. (2009) Obesity, stigma, and public health planning. Health Promotion International 24(1), 88–93. Major, B. & O’Brien, L.T. (2005) The social psychology of stigma. Annual Review of Psychology 56, 393–421. Maziekas, M.T., LeMura, L.M., Stoddard, N.M., Kaecher, S., & Martucci, T. (2003) Follow up exercise studies in paediatric obesity: implications for long term effectiveness. British Journal of Sports Medicine 37(5), 425–429. Mill, J., Austin, W., Edwards, N., et al. (2007) The influence of stigma on access to health services by persons with HIV illness. Ottawa: Canadian Institutes of Health Research. Muller, M.J., Asbeck, I., Mast, M., Langnase, K., & Grund, A. (2001) Prevention of obesity – more than an intention. Concept and first results of the Kiel Obesity Prevention Study (KOPS). International Journal of Obesity 25, S66–S74. Nihiser A.J., Lee S.M., Wechsler, H., et al. (2007) Body mass index measurement in schools. Journal of School Health 77(10), 651–671. Nonnemaker, J.M., Morgan-Lopez, A.A., Pais, J.M., & Finkelstein, E.A. (2009) Youth BMI trajectories: evidence from the NLSY97. Obesity 17(6), 1274–1280. NutriSTEP. (2009) Sudbury & District Health Unit, Sudbury, viewed 24 September 2009, . O'Brien, K.S., Hunter, J.A., & Banks, M. (2007) Implicit anti-fat bias in physical educators: physical attributes, ideology and socialization. International Journal of Obesity 31, 308–314. O’Dea, J.A. (2004)Prevention of child obesity: ‘First, do no harm’. Health Education Research 20(2) 259–265. Puhl, R.M. & Brownell, K.D. (2001) Bias, discrimination, and obesity. Obesity Research 9, 788– 805. Puhl, R.M. & Brownell, K.D. (2003) Psychosocial origins of obesity stigma: toward changing a powerful and pervasive bias. Obesity Reviews 4, 213–227. Puhl, R.M. & Heuer, C.A. (2009)The stigma of obesity: a review and update. Obesity 17(5), 941– 964. Puhl, R.M. & Latner, J.D. (2007) Stigma, obesity, and the health of the nation’s children. Psychological Bulletin 133(4), 557–580. Randall Simpson, J. & Keller, H. (2008) Nutritional screening tool for every preschooler. Sudbury and District Health Unit, Sudbury.

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Randall Simpson, J.A., Keller, H.H., Rysdale, L.A., & Beyers, J.E. (2008) Nutrition Screening Tool for Every Preschooler (NutriSTEP): validation and test–retest reliability of a parent-administered questionnaire assessing nutrition risk of preschoolers. European Journal of Clinical Nutrition 62, 770–780. Raphael, D. (2002) Social determinants of health: why is there such a gap between our knowledge and its implementation? Retrieved from . Reidpath, D.D. & Chan, K.Y. (2005) A method for the quantitative analysis of the layering of HIVrelated stigma. AIDS Care 17(4), 425–432. Robinson, L.M., McIntyre, L., & Officer, S. (2005) Welfare babies: poor children’s experiences informing healthy peer relationships in Canada. Health Promotion International 20(4), 342–350. Rock, M., McIntyre, L., & Rondeau, K. (2008) Discomforting comfort foods: stirring the pot on Kraft Dinner® and social inequality in Canada. Agriculture and Human Values 26(3), 167–176. Saguy, A.C. & Riley, K.W. (2005) Weighing both sides: morality, mortality, and framing contests over obesity. Journal of Health Politics, Policy and Law 30, 869–923. Schwartz, M.B. & Brownell, K.D. (2007) Actions necessary to prevent childhood obesity: creating the climate for change. The Journal of Law, Medicine & Ethics 35, 78–89. Sellers, E.A.C., Singh, G.R., & Sayers, S.M. (2008) Large waist but low body mass index: the metabolic syndrome in australian aboriginal children. Journal of Pediatrics 153, 222–227. SHAPES (2006). Youth healthy eating survey. University of Waterloo. Viewed September 30, 2009 . Shah, C.P. (2003) Public health and preventative medicine in Canada, 5th edn. Toronto: Elsevier. Stewart, M., Reutter, L., Makwarimba, E., et al. (2005) Determinants of health-service use by low-income people. Canadian Journal of Nursing Research 37(3), 104–131. Strawbridge, W.J., Wallhagen, M.I., & Shema, S.J. (2000) New NHLBI clinical guidelines for obesity and overweight: will they promote health? American Journal of Public Health 90(3), 340– 343. Stuber, J., Meyer, I., & Link, B. (2008) Stigma, prejudice, discrimination and health. Social Science & Medicine 67, 351–357. Szwarc, S. (2004–2005) Putting facts over fears: examining childhood anti-obesity initiatives. International Quarterly of Community Health Education 23(2), 97–116. Tjepkema, M. & Shields, M. (2005) Nutrition: findings from the Canadian Community Health Survey. Issue no. 1. Measuring obesity: overweight Canadian children and adolescents (No. Catalogue no. 82-620-MWE2005001). Ottawa, ON: Statistics Canada.

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Ungerleider, C. & Burns, T. (2004) The state and quality of Canadian public education. In D. Raphael (Ed.), Social determinants of health: Canadian perspectives. Toronto: Canadian Scholars’ Press Inc. United Kingdom Department of Health Cross-Government Obesity Unit (2009) Healthy Weight, Healthy Lives: National Child Measurement Programme Guidance for Primary Care Trusts 2009/10, viewed 16 September 2009, 〈〉. Vaidya, V. (2006) Psychosocial aspects of obesity. Advances in Psychosomatic Medicine 27, 73– 85. Vaska, V.L. & Volkmer, R. (2004) Increasing prevalence of obesity in South Australian 4-yearolds: 1995–2002. Journal of Paediatrics & Child Health 40(7), 353–355. Veugelers, P.J., & Fitzgerald, A.L. (2005) Effectiveness of school programs in preventing childhood obesity: A multilevel comparison. American Journal of Public Health 95(3), 432–435. Wang, F., Wild, T.C., Kipp, W., Kuhle, S., & Veugelers, P.J. (2009) The influence of childhood obesity on the development of self-esteem. Statistics Canada, Catalogue no.82-003-XPE. Health Reports 20(2), 21–27. Whitlock, E.P., Williams, S.B., Gold, R., Smith, P.R., & Shipman, S. (2005) Screening and interventions for childhood overweight: a summary of evidence for the US preventative services task force. Pediatrics 116(1), e125–e139. Willms, D., Tremblay, M., & Katzmarzyk, P. (2003) Geographic and demographic variation in the prevalence of overweight Canadian children. Obesity Research 11, 668–673. Wrigley, N., Warm, D., & Margetts, B. (2003) Deprivation, diet, and food-retail access: findings from the Leeds `food deserts' study’. Environment and Planning A 35, 151–188. Yager, Z. & O’Dea, J. (2008) Body image, dieting, disordered eating and activity practices among teacher trainees: implications for school-based health education and obesity prevention programs. Health Education Research, doi:10.1093/her/cyn044, viewed September 14, 2008 at .

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Developing positive approaches to nutrition education and the prevention of child and adolescent obesity: First, do no harm

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Developing positive approaches to nutrition education and the prevention of child and adolescent obesity: First, do no harm Jennifer A. O’Dea

DOI:10.1093/acprof:oso/9780199572915.003.0003

Abstract and Keywords This chapter outlines the many important benefits of childhood nutrition, including the promotion of growth, development, immunity, brain function, dental health, resistance to adult diseases, and the development of sound eating habits for life. Whilst weight control and the prevention of overweight and obesity are valid factors in teaching about healthy eating, they are not the only factors and they should not dominate messages about food and nutrition. The most effective way to promote healthy eating is to engage students with some sort of personal relevance and personal interest so that they learn to apply the nutrition theory to the food choices in their everyday lives. The chapter therefore includes some information about the perceived benefits of healthy eating from a large survey of 5,000 schoolchildren from primary and secondary schools. Students learn to become motivated towards healthy eating because of the many personal advantages it may confer on them as individuals. It also discusses the potentially adverse impact of nutrition education and weight related messages among children and their parents. As health and nutrition educators and clinical professionals, we must all remember to employ one of the most important principles of modern medicine and prevention science, ‘First, do no harm’.

Keywords: nutrition education, children, adolescents, prevention, education, schools, teachers, community, public health

Chapter summary This chapter outlines the many important benefits of childhood nutrition, including the promotion of growth, development, immunity, brain function, dental health, resistance to adult diseases, and the development of sound eating habits for life. Although weight control and the

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Developing positive approaches to nutrition education and the prevention of child and adolescent obesity: First, do no harm

prevention of overweight and obesity are valid factors in teaching about healthy eating, they are not the only factors and they should not dominate messages about food and nutrition. The most effective way to promote healthy eating is to engage students with some sort of personal relevance and personal interest so that they learn to apply the nutrition theory to the food choices in their everyday lives. This chapter therefore includes some information about the perceived benefits of healthy eating from a large survey of 5,000 schoolchildren from primary and secondary schools. Students learn to become motivated towards healthy eating because of the many personal advantages it may confer on them as individuals. This chapter also discusses the potentially adverse impact of nutrition education and weight related messages among children and their parents. As health and nutrition educators and clinical professionals, we must all remember to employ one of the most important principles of modern medicine and prevention science, ‘First, do no harm’.

Introduction The function and benefits of child and adolescent nutrition Sound child nutrition offers varied benefits, including growth, brain function, intelligence, immunity to infections, energy regulation, better concentration and behaviour, dental health, prevention of lifestyle diseases, and the development of good eating habits, many of which continue into adolescence and adulthood. Normal growth and weight control are other benefits of a nutritious diet, but these factors are often not considered most important to parents. Hence, the focus on other important positive benefits as outlined earlier is crucial in the engagement of families in health promotion. An interesting point about child and adolescent nutrition is that the food habits learned at these stages of life are often carried on and taught to future generations. This can ensure healthy food habits for many next generation children or, conversely, the continuation of poor eating habits and the risk of adult ill health.

(p.32) Children and adolescent’s perceptions of benefits derived from healthy eating The eating habits of schoolchildren aged 6–18 years were assessed in The National Nutrition and Physical Activity Study, which was conducted all around Australia from July to November, 2000. The major aims of the study were to examine the importance of nutrition and physical activity; assess the eating habits of children and adolescents and the relative nutritional quality of their diets; measure the degree of overweight and obesity among schoolchildren and examine students’ beliefs and attitudes about healthy eating and physical activity. In particular, the study aimed to understand which factors motivate healthy eating and exercise behaviours among Australian school students. Research data were collected from nearly 5,000 students from city, regional, and rural schools from every state and territory of Australia (O’Dea, 2003). Students in focus groups answered the following questions about food and nutrition. What do you think are healthy foods and drinks? Is eating healthy food important to you? Why? Why not? Which is the most important? Why? Is nutrition important? Are other things more important or less important? What are the benefits of eating healthy food? What can it do for you? Which is the most important benefit? Why?

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Developing positive approaches to nutrition education and the prevention of child and adolescent obesity: First, do no harm

Perceived benefits of healthy eating The vast majority of students (more than 75%) believed that healthy eating was important. The specific benefits of healthy eating as described by students are given in Table 3.1 with typical quotes and comments from the students involved in the study. Clearly, health educators and others whose aim it is to foster and motivate healthy eating among youth, should utilize these perspectives in order to make nutrition education messages most relevant and effective. Childhood obesity prevention: first, do no harm Before governments and other agencies leap into actions that they assume to be beneficial in the promotion of child and adolescent health and the prevention of childhood obesity, we must remember to employ one of the most important principles of modern medicine and prevention science, ‘First, do no harm’. A summary of potentially adverse effects of childhood obesity prevention activities is given in Table 3.2. Health education messages that focus on the negative impact of dietary fat, overweight, and weight control are likely to make young people feel worse about their bodies and themselves in general. Preventive activities must be examined for their unintended negative outcomes such as those known to result from unsupervised weight control attempts among children and adolescents including growth failure (Brook, Lloyd, & Wolff, 1974; Davis et al., 1978; Mallick, 1983; Lifshitz & Moses, 1988;), height stunting (Pugliese et al., 1983; Lifshitz & Moses, 1989;), delayed puberty and menarche (Lev-Ran, 1974; Frisch et al., 1980; Kulin et al., 1982), delayed bone age, bone length, and reduced bone density (Dhuper et al., 1990; Bonjour et al., 1991; Ott, 1991; Theintz et al., 1993). Health education for child obesity prevention may also result in the iatrogenesis of inappropriate weight control techniques whereby the health education programme generates unplanned, undesirable, and health damaging effects (Garner, 1988; O’Dea, 2002) such as starvation, vomiting, laxative abuse, diuretic and slimming pill usage, and cigarette smoking to suppress appetite and as a substitute for eating (Ikeda & Mitchell, 2001; Strauss & Mir, 2001). The risk of obese children and their parents adopting fad weight loss regimes is something that health educators need to be certain to avoid. (p.33) Table 3.1 Perceived benefits of healthy eating identified by children and adolescents Most important benefits

Typical comments

Cognitive function/ cognitive performance Enhanced concentration Mental alertness/mental activity Improved mental function Improved school performance

‘After eating healthy it just cleans out the system and you focus better … I focus better on school work and just everything’. (Year 11 female)

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Developing positive approaches to nutrition education and the prevention of child and adolescent obesity: First, do no harm

Most important benefits

Typical comments

Physical performance Enhanced fitness Enhanced sports performance Enhanced strength, energy, endurance

‘It helps me run … it can make me do things like run … skip … jump … hop … walk a long way’. (Year 3 female) ‘It keeps you fit … like I’ve got heaps of energy and I eat healthy foods if I want energy …’ (Year 6 male)

Positive psychological impact Cleans, refreshes, and clears mental function Self reward – done something good for self Self pride – sense of achievement Enhances self esteem Enhances self confidence Reduces guilt and anxiety Improves relationship with parents

‘It’s just a personal achievement … it’s my personal feeling like I’ve done something for myself …’ (Year 8 male) ‘I like feeling that I’ve done something good for myself, feeling good about myself … not feeling guilty’. (Year 11 female)

Physical sensation Feel good physically Feel ‘fresh and clean’ on the inside Feel ‘fresh and clean’ physically Cleansing effect Not ‘clogged up’

‘I feel good … I feel more refreshed … lighter … cleaner … I feel cleaner on the inside’. (Year 9 female) ‘Eating healthy foods is like taking a shower’ (Year 8 male) ‘I feel clean as well … it cleans your whole system …’ (Year 11 male)

Regulation of energy Creates energy Sustains energy and endurance Regulates energy Moderates energy

‘You don’t feel tired and you don’t feel held back and you don’t feel heavy’. (Year 11 male) ‘… I eat a salad and I feel … just like all fresh and I feel like going out and doing stuff … but if I sit there and pig out on junk food I feel like a blob … I can’t move …’ (Year 9 female) ‘Every time I eat fruit I feel revived … it’s energizing’. (Year 7 male)

Moderately important benefits Health protection General health enhancement Reduced sickness (colds and stomach upsets) Creates a strong immune system Maintains a strong immune system

‘My immune system is a lot stronger as well … germs don’t attack you …’ (Year 6 male)

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Developing positive approaches to nutrition education and the prevention of child and adolescent obesity: First, do no harm

Most important benefits

Typical comments

Somatic impact Tastes good Reduces hunger and effects of hunger Enhances satiety Enhances sleep Enhances relaxation

‘I get really tired if I don’t have breakfast … when I do my work I’m always really hungry … I can’t concentrate without food …’ (Year 5 female)

Future impact Enhances growth Prevents atherosclerosis Reduces future disease Enhances longevity

‘It keeps you skinny … making sure you don’t get fat’ (Year 6 female) ‘Everything feels fresher on me … you feel better … without no zits … ’ (Year 11 male) ‘It makes you get bigger …if you wouldn’t eat your food properly you’d stay the same size forever …’ (Year 3 female)

(p.34) Table 3.2 Potentially harmful and dangerous outcomes of childhood obesity prevention activities Inadvertent and undesirable outcomes of obesity prevention activities Implementation of ‘treatment’ rather than ‘prevention’ – measuring and ‘diagnosing’ student overweight or obesity; giving weight loss advice to students, ‘Prescribing’ diets or weight loss activities.

Potentially harmful and unhelpful consequences among children and adolescents ◆ Legal liability of diagnosing a condition rather than leaving that to medically trained staff ◆ Encouraging weight loss diets in growing students ◆ Labelling child with a medical ‘condition’ that is based only upon a one-off measure of BMI at one point in time ◆ Lack of student privacy

Inadvertent suggestion of dieting and other weight loss techniques – discussing weight loss rather than weight maintenance or a healthy lifestyle; inadvertent promotion of dieting and disordered eating among growing children; inadvertent suggestion that dieting is normal and desirable.

◆ Suggestion and introduction of weight loss diets in students who may not have been susceptible to dieting or body image concerns ◆ Introduction of dieting methods that are not suitable for growing children ◆ Normalization of fad diets

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Developing positive approaches to nutrition education and the prevention of child and adolescent obesity: First, do no harm

Inadvertent and undesirable outcomes of obesity prevention activities Creation of stigmatization, prejudice, and discrimination – weighing students and having them plot their BMI on a chart; inadvertently encouraging weight and BMI comparisons; labelling of students as overweight or obese; focus on weight in growth lessons rather than growth as evidenced by height; focus on weight issues rather than fitness, and overall health markers.

Potentially harmful and unhelpful consequences among children and adolescents ◆ Identification, labelling, shaming of overweight or obese students ◆ Stigmatization of overweight or obese students as having a ‘problem’ and being a ‘failure’ ◆ Promoting the idea that students will never be healthy or fit unless they lose weight ◆ Lack of focus on fitness, physical activity, better markers of health (e.g. heart rate, blood pressure, daily physical activity, social, mental, cultural, spiritual health)

Undesirable outcomes of unplanned approaches – inadvertently creating weight concerns that lead to weight loss attempts and unhealthy behaviours such as smoking for weight control and appetite control; vomiting, laxatives, avoidance of exercise; social isolation; shame of body, and depression.

◆ Students focus on weight loss rather than overall health development

Avoidance of health services; preventive screening tests; sport and PE – increasing a person’s sensitivity about their weight is likely to make them want to avoid health screenings and physical activity

◆ Likely to make students less willing to participate in health check ups because of ‘lecture’ about their weight

◆ Suggestion of weight loss at any cost – smoking, fad diets, dangerous weight loss attempts, development of diet binge cycle; disordered eating, eating disorders; exercise disorders

◆ Reduced visits to doctors, mammography ◆ Avoidance of health education, sport, PE, swimming, etc.

Promotion of fatness as a ‘sick role’ – focusing on ‘illness’ rather than focusing on health and wellbeing; giving the message that fatness equates with illness; giving the idea that slimness equates with health and fitness; missing out on the message that healthy eating and daily physical activity promote health and fitness in students of all shapes and sizes

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◆ Giving students the narrow, prejudiced, and incorrect message that ‘health’ is all about weight rather than the balanced message that fat people can be active, eat well, and be fit and healthy. ◆ Inadvertently suggesting that slim people are healthy, irrespective of their diet, physical activity, smoking status, etc.

Developing positive approaches to nutrition education and the prevention of child and adolescent obesity: First, do no harm

(p.35) Avoid further stigmatization, prejudice, and discrimination Child obesity prevention programmes and untested health education messages have the potential to further stigmatize fat children (Latner & Stunkard, 2003) and perpetuate the current prejudicial beliefs well documented among physicians and likely to exist among other health and education professionals, that fat people are ‘weak-willed, ugly and awkward’ (Young & Powell, 1985; Foster et al., 2003) and ‘gluttonous, lazy, bad, weak, stupid, worthless and lacking in self control’. Obese people are well aware that they are fat, and that healthcare professionals are biased towards them (Maddox & Liederman, 1969; Young & Powell, 1985). A recent study of 8-year-old children found similar stereotypical prejudices towards fat children (Chalker & O’Dea, 2009). In addition to obese children of both sexes being well aware of their weight problems, they have low self esteem (Strauss, 2000; O’Dea, 2006) and are currently known to exhibit high rates of extreme dieting, disordered eating, and skipping breakfast (Croll et al., 2002) as well as greater levels of emotional distress and lower expectations of their educational futures (Mellin et al., 2002; O’Dea, 2006). The last thing that obese children need is a reminder of their undesirable weight status. In addition to the further stigmatization of overweight children by focusing on the dangers of obesity and other negatively focused health messages, health educators may inadvertently discriminate against overweight children by excluding them from general participation in certain events such as school games and sports teams. This type of discrimination is known to affect overweight and obese adults who suffer discrimination in employment, salary, promotion, education, marriage, and healthcare (Gortmaker et al., 1993). Conversely, forcing unwilling participants is likely to have the undesirable outcome of making overweight children avoid physical activity. Transference and misinformation A recent study of trainee physical education teachers suggests that health education professionals may need to examine their own beliefs and attitudes towards fat people and fat children before embarking on any child obesity prevention activities and they may need specific training in order to undertake any role in child obesity prevention (Yager & O’Dea, 2009). The potential for inadvertent transference of misinformation, inappropriate advice, and prejudice from educator to child needs to be examined during the design of health education and health promotion strategies for the prevention of child overweight. In a recent study of the teachers most likely to be involved in school-based obesity prevention activities, we found a low level of nutrition knowledge and knowledge of weight control, a great deal of misinformation being conveyed from teacher to students and a very high level of body dissatisfaction and self-reported eating disorders, particularly among the young women teachers (O’Dea & Abraham, 2001). One of the most concerning findings of the study was that 85% of the teachers reported recommending strict calorie-controlled diets to their overweight students, many of whom were in the middle of their adolescent growth spurt. The potential for transference of the teacher’s own beliefs, attitudes, and prejudice as well as the delivery of ill-informed health education messages is clearly undesirable and dangerous in the prevention of child obesity.

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Undesirable outcomes of unplanned approaches Of similar potential danger in the prevention of child obesity is the dissemination of messages, whether intentioned or not, that have not been properly designed, pre-tested, and evaluated. In (p.36) an evaluation of two posters aimed at improving the body image of teenaged girls and young women (O’Dea, 2002), up to 30% of 15–18-year-old girls reported that the posters were not helpful to them because they made them feel more self-critical of their bodies; 35% reported not liking the posters; 69% did not want their own copy; 8% did not know what message the posters were meant to portray; and another 8% perceived an incorrect or harmful message from the posters. Health education programmes should, ideally, have no adverse outcomes, and this research clearly demonstrates that well-meaning health education initiatives and health messages may elude the target audience and may have subsequent negative effects. Planning of child obesity prevention programmes should involve the programme recipients, and all health education materials should be pre-tested to clearly identify the messages perceived among the target audience and to prevent unintended and potentially harmful outcomes. Avoidance of health services and preventive screening tests As a consequence of weight prejudice and discrimination, overweight adults, particularly women, are less likely to visit health professionals for preventive health screening examinations such as mammograms, pap smear tests, and gynaecologic examinations (Wee et al., 2000; Fontaine et al., 1998; Amy et al., 2006). Overweight adults are also more likely than normal weight patients to cancel medical appointments (Olson et al., 1994). Health educators involved in the treatment or prevention of child obesity need to be acutely aware of the fact that focusing on children’s weight in a negative or critical manner is also likely to produce a similar avoidance of health professionals, health services, and preventive activities by children and their parents. Further promoting the avoidance of physical activity Highlighting the problem of overweight in prevention programmes aimed at children and adolescents is likely to produce the adverse effect of making overweight children more sensitive about their weight and their self-perceived lack of athletic ability (O’Dea & Abraham, 1999) and therefore making them less likely to participate in physical activity, physical education, and sport (Shaw & Kemeny, 1989). Studies of barriers to physical activity among adolescents (Shaw and Kemeny, 1989; O’Dea, 2003) clearly identify body consciousness, lack of privacy in change rooms, and physically revealing sports uniforms as major barriers, particularly among girls. Coercing unwilling, body conscious, overweight children into sport or physical activity is likely to exacerbate these problems and further reduce their participation in physical activity, serving only to fuel the rise in child obesity. Conversely, involving children in physical activities that they enjoy is likely to boost their self-esteem, social interactions, friendships (Strauss & Pollack, 2003) and promote the very important idea that fat children can be fit and healthy (Blair, 2003). Blaming the victim The current panic about child obesity is largely fuelled by media reports that focus on the rising prevalence of child overweight and its potential health problems. The problem-based, negatively and individually focused, victim blaming approach is something that health educators ought to avoid, as it is likely to result in nothing more than the apportioning of more blame, guilt, shame, and hopelessness on fat children and their parents. As these negative reinforcing factors have

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Developing positive approaches to nutrition education and the prevention of child and adolescent obesity: First, do no harm

not been previously associated with any degree of long-term success in the past treatment or prevention of overweight in children or adults (Garner & Wooley, 1991), an evidence-based approach to current child obesity prevention efforts would do well to avoid them. A probable outcome of the negative ‘guilt, blame, shame’ individual victim blaming approach to obesity treatment and (p.37) prevention is the unfortunate adverse outcome of having overweight and obese people deliberately avoiding the problem because they do not want to be lectured about their weight, humiliated, or made to feel guilty. Child obesity prevention messages must avoid this negative, problem-based approach. Further marginalizing low SES people The prevalence of overweight is greater among socially and economically disadvantaged people and the association between lower socioeconomic status (SES) and obesity is well documented (Sobal & Stunkard, 1989; Goodman, 2003). Overweight adolescents are more likely than their normal weight peers to be socially marginalized (Strauss and Pollack, 2003). As health educators, we must be careful not to further ‘blame the victim’ by taking a judgemental, moralistic approach and inadvertently make overweight, low SES children and their parents feel even more marginalized, disadvantaged, and hopeless. Obesity as a ‘sick role’ As effective health educators, we also need to be aware of promoting child obesity as a ‘sick role’ that needs ‘medical treatment’. Sound nutrition and physical activity are essential components for overall child health as they convey many wide-ranging benefits for growth, development, brain development and cognition, immunity and disease prevention – not just child obesity prevention. All children need good nutrition and physical activity, not just obese children. The medicalization of child obesity will do little to reduce it, as the failure of dietary treatments for overweight has already demonstrated many times (Garner & Wooley, 1991). The prescription of drug treatments for obese children is increasing, lending further credibility to the myth that obesity can be ‘cured’ with a quick-fix drug treatment. At least one professional organization, of which the author is aware, has suggested that participants and groups involved in child obesity prevention should disclose all special interests such as financial affiliations with pharmaceutical companies or the weight loss industry (Berg, 2000; Society for Nutrition Education, 2002). It is of serious concern that preventive activities among children could be influenced by those aiming to make profits out of child obesity treatment or prevention.

Promoting healthy food choices in a positive way Food and nutrition are very interesting and relevant topics for children and adolescents of all ages, but all too often this material is taught in a very negative way. Teachers and other health educators often focus on telling students what NOT to eat rather than encouraging them to enjoy healthy options. This sort of approach is a very negative and unnecessarily narrow approach to nutrition education because the key components of human nutrition are balance, variety, enjoyment, and moderation. In this regard, there is no one food that cannot be included in a balanced diet. Teachers need to approach the topic of nutrition education using the ‘balance, variety, moderation’ messages in a consistent manner.

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Developing positive approaches to nutrition education and the prevention of child and adolescent obesity: First, do no harm

Following is a summary table of nutrition education tips about how to combine curricula, involve other teaching departments and implementing a positive, holistic approach to teaching about various health issues in a positive way. Some tips for promoting messages about healthy food, nutrition, growth and health in a positive, non-blaming, non-shaming way ◆ Keep the focus of food and nutrition messages positive rather than negative, critical or blaming. (p.38) ◆ Remember to talk about food as well as nutrients. ◆ Discuss the practical and relevant aspects of foods as well as the theoretical aspects of nutrients. ◆ Do not use the term ‘junk food’ – it simply creates blame and guilt. ◆ Avoid focussing on the sugar and fat content of food and rather, focus on the positive benefits of healthy food choices. ◆ Promote the nutritional benefits of foods and the enjoyment of healthy foods. For example, have young people enjoy tasting healthy foods rather than focus on the fat content of ‘unhealthy’ foods. ◆ Taste tests of fruits and vegetables are a fun way to introduce students to healthy eating. ◆ Never refer to ‘good’ or ‘bad’ foods. Reinforce the major nutrition themes of variety, balance, enjoyment, and moderation. ◆ Don’t make negative comments about your own weight your diet or your poor eating habits. Try to be a sensible role model. ◆ Try to be seen choosing and enjoying healthy options for yourself. ◆ Encourage young people to become involved in the preparation and enjoyment of healthy foods and snacks at school and home. ◆ Focus on what students can enjoy rather than what they should avoid. ◆ Couple lessons or design cross-curricular activities on growth and development, food and nutrition with body image and self-esteem building lessons about students’ diversity, uniqueness, individual differences, individual interests and talents, self acceptance and tolerance of others. ◆ Focus on positive messages such as expected body changes, enjoyment of foods and the benefits of physical growth and development for both boys and girls, e.g. strength, skills development, abilities. ◆ Focus on the positive aspects of growth and development, e.g. monitor changes in height but not weight.

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◆ Explain that weight and height and appetite are expected to increase with growth. Growing, pubertal adolescents will have voracious appetites and they need to know that this is normal. ◆ Encourage some non-competitive, collaborative physical activity using various games and skill development. Focus on self competence and personal achievements rather than competitive results. ◆ Children with a muscular body build are likely to have a heavier weight and BMI. Very tall children also tend to have a greater BMI. Explain that these students are not overweight, but that their weight is composed of more muscle and/or height than others. ◆ Reinforce that being physically active is healthy at any size or shape and that movement can be undertaken and enjoyed in many different types of activities. ◆ Reinforce the idea that students should enjoy their physical activities so that they can continue to enjoy some aspect of fitness and movement for life. ◆ Encourage students to enjoy cooking. ◆ Don’t forget to include boys and young men – they are interested in nutrition, cookery and body image and they are sensitive about their bodies too! References Bibliography references: Amy, N.K., Aarlborg, A., Lyons, P., & Karanen, L. (2006) Barriers to routine gynecological cancer screening for White and African-American obese women. International Journal of Obesity 30(1), 147–155. Berg, F. (2000) How the diet industry exerts control. In Women afraid to eat pp.193–211. Hettinger, North Dakota: Healthy Weight Network. Blair, S.N. (2003) Revisiting fitness and fatness as predictors of mortality. Clinical Journal of Sport Medicine 13(5), 319–320. Bonjour, J., Theintz, G., Buchs, S.B., Slosman, D., & Rizzoli, R. (1991) Critical years and stage of puberty for spinal and femoral bone mass accumulation during adolescence. Journal of Clinical Endocrinology and Metabolism 73, 555–563. Brook. C., Lloyd. J., & Wolff. O. (1974) Rapid weight loss in children. BMJ 3, 44–45. Chalker, B. & O’Dea, J.A. (2009) Fat kids can't do maths: negative body weight stereotyping and associations with academic competence and participation in school activities among primary school children. The Open Education Journal 2(7), 71–77. doi: 10.2174/1874920800902010071

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Lifshitz, F. & Moses, N. (1988) Nutritional dwarfing: growth, dieting and fear of obesity. Journal of the American College of Nutrition 7, 367–376. Lifshitz, F. & Moses, N. (1989) A complication of dietary treatment of hypercholesterolaemia. American Journal of Diseases in Children 143, 537–542. Maddox, G.L. & Liederman, V. (1969) Overweight as a social disability with medical implications. Journal of Medical Education 44, 214–220. Mallick, M.J. (1983) Health hazards of obesity and weight control in children: a review of the literature. American Journal of Public Health 73, 78–82. Mellin, A.E., Neumark-Sztainer, D., Story, M., et al. (2002) Unhealthy behaviours and psychosocial difficulties among overweight adolescents: the potential impact of familial factors. Journal of Adolescent Health 31, 145–153. Olson, C.L., Schumaker, H.D., & Yawn, B.P. (1994) Overweight women delay medical care. Archives of Family Medicine 3(10), 888–892. O’Dea, J.A. (2002) Can body image education be harmful to adolescent females? Eating Disorders 10, 1–13. O’Dea, J.A. (2003) Why do kids eat healthful food? Perceived benefits of and barriers to healthful eating and physical activity among children and adolescents. Journal of the American Dietetic Association 103, 497–501. O’Dea, J.A. (2006) Self-concept, self esteem and body weight in adolescent females: a three- year longitudinal study. Journal of Health Psychology. 11(4), 599–611. O’Dea, J. & Abraham, S. (2001). Knowledge, beliefs, attitudes, and behaviours related to weight control, eating disorders, and body image in Australian trainee home economics and physical education teachers. Journal of Nutrition Education 33, 332–340. O’Dea, J., Abraham, S., & Heard, R. (1996) Food habits, body image and weight control practices of young male and female adolescents. Australian Journal of Nutrition and Dietetics 53, 32–38. O’Dea J. & Maloney, D. (2001) Preventing eating and body image problems in children and adolescents using the Health Promoting Schools Framework. Journal of School Health. 70(1), 18–21. Ott, S.M. (1991). Bone density in adolescents. New England Journal of Medicine 325, 1646– 1647. Pugliese, M., Lifshitz, F., Grad, G., Fort, P., & Marks-Katz, M. (1983) Fear of obesity: a cause of short stature and delayed puberty. New England Journal of Medicine 309, 513–518. Rayner, P. & Court. J. (1974) The effect of dietary restriction and anorectic drugs on linear growth velocity in childhood obesity. Archives of Diseases in Children 49, 822–823.

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Developing positive approaches to nutrition education and the prevention of child and adolescent obesity: First, do no harm

Robison, J.I., Hoerr, S.L., Petersmarck, K.A., & Anderson, J.V. (1995) Redefining success in obesity intervention: the new paradigm. Journal of the American Dietetic Association 95(4), 422– 423. Shaw, S.M. & Kemeny, L. (1989) Fitness promotion for adolescent girls: the impact and effectiveness of promotional material which emphasises the slim ideal. Adolescence 24, 677– 687. Sobal, J. & Stunkard, A.J. (1989) Socioeconomic status and obesity: a review of the literature. Psychological Bulletin 105, 260–275. Society For Nutrition Education (2002) Guidelines for childhood obesity prevention programs: promoting healthy weight in children, URL: Strauss, R.S. (2000) Childhood obesity and self-esteem. Pediatrics 105(1). URL: Strauss, R.S. & Mir, H.M. (2001) Smoking and weight loss attempts in overweight and normalweight adolescents. International Journal of Obesity 25(9), 1381–1385. Strauss, R.S. & Pollack, H.A. (2003) Social marginalization of overweight children. Archives of Pediatrics and Adolescent Medicine 157(8), 746–752. Theintz, G.E., Howald, H., Weiss, U., & Sizonenko, C. (1993). Evidence for a reduction of growth potential in adolescent female gymnasts. Journal of Pediatrics 122, 306–313. Yager, Z. & O’Dea, J.A. (2009) Body image, dieting and eating disorders among health education and physical education teachers: implications for school-based health education and childhood obesity prevention. Health Education Research 24(3), 472–483. doi: 10.1093/her/cyn044 Young L.M. & Powell, B. (1985) The effects of obesity on the clinical judgements of health care professionals. Journal of Health and Social Behavior 26, 233–246. Wee, C.C., McCarthy, E.P., Davis, R.B., & Phillips, R.S. (2000) Annals of Internal Medicine 132(9), 732–734.

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Low family income and the overweight status of Canadian adolescents

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Low family income and the overweight status of Canadian adolescents Peter Burton Shelley Phipps

DOI:10.1093/acprof:oso/9780199572915.003.0004

Abstract and Keywords In Canada, as in many other countries, the prevalence of overweight/obesity among children and youth has more than doubled over the past 25 years. Based on self-reports of height and weight, data indicates that in 2005, 19.4% of Canadian girls aged 12 to 17 were overweight and 3.5% were obese; 24.1% of Canadian boys the same age were over-weight and 6.1% were obese. A variety of explanations for high levels of obesity among young people have been examined in the literature. These include poor eating habits, lack of exercise and/or too much sedentary behaviour, parental obesity and/or genetic factors, and subjective social status. Other studies have also explored the role of low family income as a correlate of youth overweight status and it is upon this literature, in particular, that this chapter builds. In Canada, despite a unanimous vote in the House of Commons in 1989 to end child poverty by the year 2000, in fact, no progress has been made; 15.3% of children were poor in 1991 and this increased steadily to 16.8% were poor in 2004. Current high levels of unemployment in Canada are likely to mean further increases in child poverty. Thus, both child poverty and child obesity are problems, and the chapter explores the connections between the two. The goals are to estimate the relationship between obesity and low family income for Canadian teens and to examine potential pathways for this relationship. In particular, it focuses on the teen's level of physical activity, his or her eating habits and family food security, hours spent in paid work, and ‘sense of belonging to the local community’.

Keywords: social class, socioeconomic status, SES, poverty, obesity, prevalence, children, adolescents, schools, Canada

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Low family income and the overweight status of Canadian adolescents

Chapter summary In Canada, as in many other countries, the prevalence of overweight/obesity among children and youth has more than doubled over the past 25 years (Shields, 2005). Based on self-reports of height and weight, our data indicate that in 2005, 19.4% of Canadian girls aged 12 to 17 were overweight and 3.5% were obese; 24.1% of Canadian boys the same age were over-weight and 6.1% were obese. A variety of explanations for high levels of obesity among young people have been examined in the literature. These include: poor eating habits (e.g., Ball et al., 2008), lack of exercise and/or too much sedentary behaviour (e.g., Janssen et al., 2004), parental obesity and/or genetic factors (Lin et al., 2004), and subjective social status (Adina et al., 2008). Other studies have also explored the role of low family income as a correlate of youth overweight status (e.g., O’Dea, 2003, 2008; Phipps et al., 2005; Wang & Zhang, 2006) and it is upon this literature, in particular, that we build. In Canada, despite a unanimous vote in the House of Commons in 1989 to end child poverty by the year 2000, in fact, no progress has been made; 15.3% of children were poor in 1991 and this increased steadily to 16.8% poor in 2004 (LIS Key Figures, 2009). Current high levels of unemployment in Canada are likely to mean further increases in child poverty. Thus, both child poverty and child obesity are problems; in this chapter we explore connections between the two. Our goals are to estimate the relationship between obesity and low family income for Canadian teens and to examine potential pathways for this relationship. In particular, we focus on the teen’s level of physical activity, his or her eating habits and family food security, hours spent in paid work, and ‘sense of belonging to the local community’.

Introduction In the current chapter, we use Cycle 3.1 of the Canada Community Health Survey, a very large cross-sectional survey carried out by Statistics Canada in 2006, representative of the noninstitutionalized Canadian population aged 12 and over. Interviews were carried out using computer-assisted interviewing technology by trained Statistics Canada staff (approximately half of the interviews were in person with the remainder done over the phone). One knowledgeable member of the household was asked to provide basic demographic information about the household (including parental education levels and family income). Then, one member of each sampled household was randomly selected for a more in-depth interview. CCHS respondents self reported height and weight (Statistics Canada, 2006b). Other studies indicate that adolescent self reports correlate well with measured height and weight, though it is likely we underestimate overweight and obesity prevalence with these data (Elgar et al., 2005). Of the 12,317 adolescents aged 12 through 17 who are respondents to Cycle 3.1 of the CCHS, 11,350 (92%) responded to the height/weight questions necessary to construct BMI (weight/ height2). (p.43) Overweight and obesity status are identified by comparing the adolescent’s BMI with the age/sex cut points derived using data from six countries by Cole et al. (2000). Essentially, these cut-offs define a child as overweight or obese if his or her current BMI is on a growth path that will lead to overweight or obesity in adulthood.

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Low family income and the overweight status of Canadian adolescents

Respondents with missing data for any analysis variable were excluded. Notably, 2692 observations were lost due to missing family income. Following exclusions for non-response to other questions used in our analysis, we have a sample of 3191 girls and 3422 boys.

Methods We estimate logit models of the probability of being overweight or obese. Models are estimated separately for boys and girls. In the first specification we include only an indicator that the child lives in a family with income in the bottom 20% of the Canadian income distribution.1 In the second specification, we add explanatory variables that may serve as pathways from low family income to child obesity. In each case, it seems plausible that the variable may both correlate with family income and be a factor in understanding teen weight status. The first set of additional explanatory variables describe the teen: age (15 to 17 versus 12 to 14), immigrant status, and ethnicity (non-white). Immigrant families may have both lower income (Picot, 2004) and different cultural practices that correlate (positively or negatively) with child weight status; similarly, adolescents with different ethnic backgrounds may have different body types, body images, and/or eating habits, which may correlate with weight status (see, for example, O’Dea, 2008).2 A second set of explanatory variables describe the family environment: lone-parent versus twoparent family, highest education level achieved by a parent, and region of residence. Lone parents may both be less able to afford and have less time to cook healthy foods or to drive teens to recreational activities. Also, lone parents experience higher levels of stress (Burton and Phipps, 2009), which can increase cravings for high fat/high sugar foods (e.g., Rosmond, 2005). If unhealthy foods are available in the home, they will also be accessible to the children. Parents with higher levels of education can be expected to have more secure jobs and higher incomes; they may also have more knowledge of nutrition and healthy living practices.3 A third set of variables describe behaviour, restrictions on behaviour (physical activity, activity limitations, daily intake of fruits/vegetables), and/or feelings of the young teen (self-assessed sense of ‘belonging to the local community’) that may be connected with low family income. It is plausible that lower-income teens have fewer opportunities to be physically active than their more affluent peers. For example, families may not be able to afford to pay for involvement in sports or recreation; lower-income neighbourhoods may offer fewer parks or facilities or not feel safe (see Oliver and Hayes, 2005). We measure each teen’s level of physical activity according to their ‘daily energy expenditure’. This is constructed for each respondent in the CCHS from information collected about types of physical activities and amount of time spent in each. Different forms of physical activities are more energy-consuming than others (e.g., hockey versus fishing); (p.44) thus, for each activity in which the teen participated, Statistics Canada multiplies frequency X duration X estimated kilocalories expended per kilogram of body weight for that activity, assuming a low intensity level (see Statistics Canada, 2006a, p. 102). These are summed across all activities and divided by 365 to obtain estimated daily energy expenditure. Many teens with activity limitations may be unable to engage in a healthy, active life-style, increasing the chances of being overweight relative to their peers. To the extent that the activity

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Low family income and the overweight status of Canadian adolescents

limitation imposes a financial burden on the family (e.g., through reduced labour market participation of a parent), activity limitations may be more prevalent in lower-income families. Eating more fruit and vegetables is recommended as part of a healthy life-style, but may be less affordable for lower-income families, particularly in more isolated regions and during Canadian winters when fresh fruit and vegetables may be more expensive than other foods. Since only four provinces (PEI, Ontario, Alberta, and BC) participated in the nutrition sub-module, we provide separate estimates to investigate diet as a pathway from low-income to child weight status. Another way to approach understanding a potential link between low income and poor nutrition is through a rich set of food security questions answered by respondents to the CCHS. This is, again, a sub-module of the survey and four provinces (Newfoundland, New Brunswick, Saskatchewan, and Manitoba) did not participate. The question we use here is: ‘You and other household members couldn’t afford to eat balanced meals. In the past twelve months was that often true, sometimes true, or never true’. From this information, we construct a ‘food insecurity’ variable =1 if the respondent answered ‘often’ or ‘sometimes’. Note that food insecurity is not the same thing as low income insofar as it will also reflect prices and availability of healthy food in the local area. An issue that has not received much attention in the literature on adolescent obesity is that lower-income teens seem plausibly more likely to take on paid jobs. If paid hours are high, this has the potential to limit time available for a physically active life-style (though some jobs will involve physical labour). Also, many teens work at fast-food establishments that may encourage them to eat unhealthy foods (e.g., Thompson et al. (2004) demonstrate longitudinal increases in BMI for adolescent girls who purchase more food away from home). Although we do not know the nature of the paid work done, the CCHS asks 15- to 17-year-olds about usual paid hours per week. In a third set of regressions, we include a variable describing the adolescent’s self-assessed sense of ‘belonging’. In Europe, both scholars and policy makers are increasingly focused on ‘social exclusion’ rather than simply on poverty as an important policy problem (see, for example, Micklewright, 2002). Although low income, especially long-term low income is viewed as an important component of social exclusion (e.g., Atkinson, 1998), social exclusion is a broader concept than poverty. For example, a child with a disability or a child who is a new immigrant might feel socially excluded though he or she might not live in a low-income household; nevertheless, living in low income is likely to generate feelings of exclusion (if, for example, the teen is unable to afford clothing similar to peers, to participate in school trips, or to have a cell phone on which to text message). In a recent paper, Adina et al. (2008) provide evidence that girls who feel less popular are more likely to gain weight. Although we have no information about feelings of popularity, in the CCHS, all respondents are asked: ‘How would you describe your sense of belonging to your local community? Would you say it is: very strong, somewhat strong, somewhat weak, very weak?’ We include an indicator that the child feels less than a ‘very strong’ sense of belonging to his or her local community as an indicator of potential ‘social exclusion’. We add this variable separately given that it is plausibly endogenous

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Low family income and the overweight status of Canadian adolescents

(direction of causation could run from being obese to feeling you don’t belong or from feeling you don’t belong to becoming obese). All reported estimates use cross-sectional survey weights. Estimation was carried using the software package STATA. (p.45)

Descriptive statistics Are low-income adolescents more likely to be overweight? Figure 4.1 indicates that Canadian teens from lower-income families are, unconditionally, more likely to be overweight than children from moderate or higher-income families. Although boys are more likely to be overweight than girls, the association between low family income and overweight status is somewhat more

Fig. 4.1 Overweight status by 2005 family income quintile. Canadian 12 to 17 year olds (percent).

pronounced for the girls. Figure 4.2 presents the same profiles for obesity; very similar patterns are evident, with the low-income association particularly strong for the girls. How are children from low-income families different? We next illustrate the connection with low-income status for a selected set of variables that might serve as pathways from low income to higher levels of overweight and obesity for Canadian adolescents. Notice, first, in Fig. 4.3, that 37.8% of teens in the bottom quintile of the Canadian income distribution live in lone-parent families compared to just 6.2% in the top quintile. As indicated in Fig. 4.4, bottom-quintile children are also more likely to have a parent with a low education. In terms of teen behaviour, Fig. 4.5 shows that girls in lower-income families are somewhat less active than girls from higher-income families. Boys are, on average, more active than girls, but there is no apparent socioeconomic pattern evident. Although boys are more active, girls are more likely to eat their vegetables,4 especially if they are from higher-income families (see Fig. 4.6). More generally, Fig. 4.7 illustrates a link between low income and nutrition insofar as about 22% of adolescents in the bottom quintile of the Canadian income distribution report that their families cannot always afford a balanced diet5; food scarcity basically does not exist for children in the top quintile. Although it seems plausible that teens from lower-income families may be more likely to take up part-time jobs in order to supplement family income, Fig. 4.8 illustrates that there is no (p.46)

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Low family income and the overweight status of Canadian adolescents

(p.47)

Fig. 4.2 Percent obese by 2005 family income quintile. Canadian 12 to 17 year olds.

Fig. 4.3 Lone-parent family by 2005 family income quintile (percent).

Fig. 4.4 Parent(s) with less than high-school education by 2005 family income quintile (percent).

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Low family income and the overweight status of Canadian adolescents

(p.48)

Fig. 4.5 Daily energy expenditure (kilocalories per kg of body weight per day).

Fig. 4.6 Daily servings of fruits/vegetables by 2005 family income quintile.

Fig. 4.7 Cannot always afford to eat balanced meals, adolescents by 2005 family income quintile.

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Low family income and the overweight status of Canadian adolescents

apparent difference in hours of paid work performed by 15- to 17-year-old boys in high- and low-income families (averages include zeroes). There are, however, differences in participation in paid work by family income level for 15- to 17-year-old girls. In particular, girls from families with income in the top 20% of the Canadian income distribution on average work fewer hours per week (15.2 compared to 18.3 for lower-income girls).

Fig. 4.8 Teen weekly paid hours by 2005 family income quintile.

Finally, Fig. 4.9 illustrates that both boys and girls from lower-income families are less likely to feel a strong sense of belonging to their community, with this pattern again more striking for the girls.

Multivariate results Tables 4.1 and 4.2 report odds ratios from estimated logit models of the probability of being overweight or obese, respectively. For girls, specification A in Table 4.1 confirms a statistically significant relationship between overweight status and family income; girls from lower-income families are about 1.5 times more likely to be overweight than girls from middle or higherincome families. The relationship between family income and overweight status is not statistically significant for boys.6 Table 4.2 indicates an even larger association between low family income and the probability of obesity for teen girls; again, there is not a statistically significant relationship for teen boys. Finding that low income is correlated with obesity for adolescent girls but not boys is consistent with literature from other countries (for example, O’Dea, 2008 for Australia, Wang and Zhang, 2006 for the US). Pathways from low-income to overweight/obese status? We next explore possible pathways from low income to overweight/obese status by re-estimating logit models for the probability that the teen is overweight/obese, adding the covariates described earlier (with the exception of ‘belonging’). Means for all explanatory variables are reported in Appendix Table 4.1. Odds ratios are reported in Specifications B in Tables 4.1 and 4.2. (p.49)

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Low family income and the overweight status of Canadian adolescents

Fig. 4.9 Sense of belonging to community ‘very strong’ by 2005 family income quintile (percent).

Table 4.1 Odds ratios for logit models of the association between low family income and the probability of overweight status. Canadian 12 to 17 year olds

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Low family income and the overweight status of Canadian adolescents

Girls

Boys

A

B

C

A

B

C

1.48** (0.24)

1.22 (0.23)

1.20 (0.23)

1.24 (0.18)

1.01 (0.16)

1.01 (0.16)

Age 15 to 17

1.08 (0.14)

1.01 (0.14)

0.95 (0.10)

0.92 (0.10)

Non-white

0.97 (0.17)

0.95 (0.17)

1.29 (0.21)

1.27 (0.20)

Immigrant

1.17 (0.38)

1.14 (0.36)

1.16 (0.29)

1.16 (0.29)

Lone-parent family

1.33* (0.22)

1.29 (0.22)

1.13 (0.17)

1.12 (0.17)

Highest parental education less than high school

1.90** (0.56)

1.88** (0.56)

1.03 (0.28)

1.03 (0.28)

Highest parental education post-secondary

0.93 (0.16)

0.91 (0.15)

0.70** (0.11)

0.70** (0.11)

Atlantic

1.69** (0.32)

1.73** (0.33)

1.32* (0.21)

1.32* (0.21)

Quebec

0.93 (0.19)

0.91 (0.18)

0.85 (0.14)

0.84 (0.13)

West

1.10 (0.17)

1.09 (0.17)

0.89 (0.12)

0.89 (0.12)

Activity limited

1.35*** (0.21)

1.33** (0.21)

1.44*** (0.19)

1.43*** (0.19)

Daily energy expenditure

0.98 (0.02)

0.98 (0.02)

0.98* (0.01)

0.98* (0.09)

Low income

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Low family income and the overweight status of Canadian adolescents

Girls A

Boys B

Belonging to community ‘very strong’ Number of Obs

C

A

B

0.68** (0.12) 3191

3191

3191

C 0.87 (0.12)

3422

3422

3422

Standard errors are presented in parentheses. *** indicates statistically significant at 99%; ** indicates statistically significant at 95%; * indicates statistically significant at 90%.

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Low family income and the overweight status of Canadian adolescents

(p.50)

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Low family income and the overweight status of Canadian adolescents

Table 4.2 Odds ratios for logit models of the association between low family income and the probability of being obese. Canadian 12 to 17 year olds Girls

Boys

A

B

C

A

B

C

2.82*** (0.83)

2.75*** (1.03)

2.70*** (1.0)

1.47 (0.40)

1.14 (0.32)

1.16 (0.32)

Age 15 to 17

1.65* (0.46)

1.55 (0.42)

1.20 (0.23)

1.14 (0.21)

Non-white

0.50* (0.18)

0.49* (0.18)

1.40 (0.37)

1.36 (0.35)

Immigrant

0.95 (0.70)

0.94 (0.69)

0.99 (0.45)

0.99 (0.44)

Lone-parent family

0.96 (0.30)

0.94 (0.30)

1.40 (0.37)

1.39 (0.36)

Highest parental education less than high school

1.07 (0.58)

1.04 (0.57)

0.85 (0.37)

0.83 (0.36)

Highest parental education post-secondary

0.85 (0.28)

0.82 (0.27)

0.72 (0.18)

0.72 (0.18)

Atlantic

1.43 (0.51)

1.45 (0.52)

0.86 (0.24)

0.87 (0.25)

Quebec

0.99 (0.39)

0.97 (0.39)

0.61 (0.17)

0.60* (0.17)

West

1.04 (0.33)

1.03 (0.33)

0.87 (0.20)

0.88 (0.20)

Activity limited

2.89*** (0.84)

2.82*** (0.80)

1.61** (0.36)

1.60** (0.37)

Quintile 1

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Low family income and the overweight status of Canadian adolescents

Girls A Daily energy expenditure

Boys B

C

0.94 (0.07)

0.94 (0.07)

Belonging to community ‘very strong’ Number of Obs

A

B

C

0.95* (0.02)

0.96* (0.03)

0.71 (0.24) 3171

3171

3171

0.71 (0.18) 3393

3393

3393

Standard errors are presented in parentheses. *** indicates statistically significant at 99%; ** indicates statistically significant at 95%; * indicates statistically significant at 90%.

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Low family income and the overweight status of Canadian adolescents

For girls, living in a lone-parent family, having a parent (or parents) with low education, living in the Atlantic, and having an activity limitation7 are all potential pathways through which low income is associated with overweight status. Girls living in lone-parent families have higher odds of being overweight (odds ratio = 1.33); girls whose parents have not completed high school are almost twice as likely to be overweight as girls whose parents have high school diplomas (odds ratio = 1.90); girls living in Atlantic Canada are also much more likely to be overweight than girls in Ontario, all else equal (odds ratio = 1.69). The size of the low-income indicator itself falls in size and is no longer statistically significant after these pathway variables are added to the model. Physical activity (as measured through daily energy expenditure) does not have a statistically significant association with the probability of being overweight for adolescent girls. (p.51) Table 4.2 indicates that the association between low family income and obesity remains very large and highly statistically significant even after inclusion of the full additional set of covariates. Notice that, for girls, being non-white is associated with 50% lower odds of being obese. For adolescents living in four Canadian provinces (PEI, Ontario, Alberta, and BC), the CCHS provides data about daily consumption of fruits and vegetables. This measure of nutrition does not have a statistically significant relationship with overweight status for Canadian teen girls. (As we are working with a sub-sample of the data, we report selected odds ratios separately in Table 4.3.) Janssen et al. (2004) also found no relationship between dietary habits and overweight status, though they did find significant associations for inactivity, which, for girls, we do not. If, however, we make use of the teens’ report that the family could not always afford a balanced diet; there is, other things equal, a strong association with both overweight and obese status for the girls. As this information is only available for teens living in PEI, Nova Scotia, Ontario, Alberta, and BC, selected results are, again, reported separately in Table 4.4. Contrary to our expectations, 15- to 17-year-old girls with part-time jobs (between 10 and 19 hours) are much less likely to be obese than those without part-time work (odds ratio = 0.46; see Table 4.5).8 However, a sizable positive (though not statistically significant) association between obesity and high paid hours (more than 20 per week) is apparent, suggesting future research on this issue might be warranted. Specification C in Table 4.1 adds the indicator that the teen feels a ‘very strong’ sense of belonging to her local community. For girls, the probability of being overweight is lower (odds ratio = 0.68) when belonging is very strong. Although clearly this is an important relationship, with cross-sectional data, we are not able to say anything about the direction of causation. O’Dea (2006), for example, finds a relative decline in close friendship scores for girls with high BMI; Adina et al. (2008) find that girls who feel less popular are more likely to gain weight. For boys, the estimated association between family low income and the probability of being overweight is smaller and remains statistically insignificant following the inclusion of the set of potential pathway variables (see Specification B in Table 4.1). As was also true for the girls, parental education has an important association with the probability a teen boy is overweight – if a parent has post-secondary level education the probability that a teen boy will be overweight

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Low family income and the overweight status of Canadian adolescents

is only 70% as high as if the highest level of education in the family is high school. Activity limitation again has strong positive associations with the probability of being overweight with the size of the association very similar to that estimated for teen girls. One factor that correlates significantly with overweight/obese status for the boys that did not play a role for the girls is exercise. Boys who expend more energy daily are significantly less likely to be overweight. Care should be taken in the interpretation of the odds ratios in this case; they indicate the relative odds of being overweight or obese per kcal of energy expended per day per kg of body weight. For instance, boys who spend an additional hour per day at activities such as bicycling, skating, golfing, skiing, or tennis (which expend approximately 4 kcal/kg of weight) have a probability of being overweight that is 92% (i.e., 0.984) and a probability of being obese that is 82% (i.e., 0.954) of those who do not have this additional hour of exercise (using Specification B). Neither fruit and vegetable consumption (see Table 4.3) nor family food insecurity (see Table 4.4) have statistically significant associations with overweight/obese status for the boys. However, as indicated in Table 4.5, part-time work (10 to 19 hours per week) is associated with a lower probability of being obese (odds ratio = 0.48) for the 15- to 17-year-old boys as well as for the girls. In contrast with results for adolescent girls, no statistically significant association between feeling a strong sense of belonging and overweight status is apparent for boys (see Specifications C in Tables 4.1 and 4.2). (p.52) Table 4.3 Selected odds ratios for logit models of the association between daily consumption of fruits/vegetables, low family income and the probability of being overweight/obese. 12 to 17 year olds living in PEI, Ontario, Alberta and BC Girls

Boys

Obese

Overweight

Obese

Overweight

Low income

2.48* (1.20)

1.08 (0.76)

1.13 (0.43)

0.88 (0.20)

Daily servings of fruits/vegetables

0.99 (0.08)

0.96 (0.04)

1.03 (0.06)

0.98 (0.03)

Number of Obs

1689

1689

1881

1881

Additional controls = daily energy expenditure, child age, ethnicity, immigrant status, activity limitation, lone-parent family, highest parental education level, region, strong feeling of belonging to local community. Standard errors are presented in parentheses. *** indicates statistically significant at 99%; ** indicates statistically significant at 95%; * indicates statistically significant at 90%. To sum up, for Canadian adolescent girls, we find a strong association between family income and overweight and, especially, obese status; the same relationship is not apparent for Canadian adolescent boys. Important pathways from family income to overweight status include: parental education, family structure, family food security, and the teen’s sense of belonging to the local community.

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Low family income and the overweight status of Canadian adolescents

Discussion/conclusions Echoing results reported for Australia (O’Dea, 2008) and the US (Wang and Zhang, 2006), we find that lower-income girls are more likely to be overweight/obese than middle- or higherincome girls, but that no statistically significant income gradient is apparent for the boys. Moreover, for the boys, no income-related patterns are evident in behaviours that past research has suggested should matter for obese/overweight status (e.g., physical activity, consumption of fruits/vegetables). Nor is such a pattern apparent in the paid work patterns of Canadian adolescent boys, a new potential avenue we consider here (but which perhaps warrants future research that distinguishes the type of paid work done – e.g., working in a fast-food restaurant versus mowing lawns). For girls, on the other hand, not only is low income correlated with overweight/obese status, but it is also true that girls are less active, do more paid work, and eat fewer servings of fruits/ vegetables when they come from lower-income families. Understanding why these underlying Table 4.4 Selected odds ratios for logit models of the association between food insecurity, low family income and the probability of being overweight/obese. 12 to 17 year olds living in PEI, Nova Scotia, Ontario, Alberta and BC Girls

Boys

Obese

Overweight

Obese

Overweight

Low income

2.17* (1.01)

1.10 (0.25)

1.22 (0.32)

0.93 (0.16)

Food insecure

3.31** (1.56)

1.73* (0.49)

1.60 (0.88)

1.50 (0.39)

Number of Obs

2566

2566

2814

2814

Additional controls = daily energy expenditure, child age, ethnicity, immigrant status, activity limitation, lone-parent family, highest parental education level, region, strong feeling of belonging to local community. Standard errors are presented in parentheses. *** indicates statistically significant at 99%; ** indicates statistically significant at 95%; * indicates statistically significant at 90%. (p.53) Table 4.5 Selected odds ratios for logit models of the association between paid work, low family income and the probability of being overweight/obese. 15 to 17 year olds Girls

Boys

Obese

Overweight

Obese

Overweight

Low income

3.92*** (1.76)

1.25 (0.22)

1.25 (0.49)

1.06 (0.22)

1 to 9 paid hours per week

0.76 (0.42)

0.90 (0.26)

0.43 (0.23)

0.70 (0.22)

10 to 19 paid hours per week

0.46* (0.20)

0.95 (0.24)

0.48* (0.19)

0.80 (0.18)

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Low family income and the overweight status of Canadian adolescents

Girls

Boys

Obese

Overweight

Obese

Overweight

20+ paid hours per week

1.38 (0.66)

1.21 (0.37)

1.05 (0.49)

0.86 (0.20)

Not in school

0.27** (0.18)

0.46** (0.15)

0.79 (0.36)

0.85 (0.23)

Number of Obs

1580

1580

1651

1651

Base category for paid work hours is no paid hours. Additional controls = daily energy expenditure, child age, ethnicity, immigrant status, activity limitation, lone-parent family, highest parental education level, region, strong feeling of belonging to local community. Standard errors are presented in parentheses. *** indicates statistically significant at 99%; ** indicates statistically significant at 95%; * indicates statistically significant at 90%. behaviours exhibit income-related patterns for girls but not for boys would be a useful direction for future studies. For example, it could be the case that girls from lower-income families are asked to do more childcare or housework, leaving them less time to be physically active. Preliminary calculations using time use data from the 2005 Statistics Canada General Social Survey indicate that, indeed, lower-income girls do considerably more unpaid work than other Canadian adolescents (e.g., 11.6 hours of housework and childcare per week compared to 4.8 hours for high-income girls; boys do about 6 hours per week regardless of family income). For both boys and girls, we find that lower-income adolescents are less likely to feel a strong sense of belonging to their local communities, though the difference by family income is much larger for the girls than the boys. We further find that girls who lack a sense of belonging are more likely to be overweight; future research with longitudinal data might usefully probe the direction of causation here. In terms of preventing childhood obesity, the topic of this book, these results are a reminder that reducing the number of children who live in poverty could help reduce the number of children who are overweight or obese. More children would be able to afford a balanced diet, more children would be able to participate in healthy recreational activities, fewer children would feel excluded.

Acknowledgements We thank both the Canadian Institute for Advanced Research and the Canadian Labour Market and Skills Researcher Network for funding and Sarah MacPhee for excellent research assistance. References Bibliography references: Adina, R., Lemeshow, S.M., Fisher, L., et al. (2008) Subjective social status in the school and change in adiposity in female adolescents. Archives of Pediatrics and Adolescent Medicine 162(1), 23–28.

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Low family income and the overweight status of Canadian adolescents

Atkinson, A.B. (1998) Social exclusion, poverty and unemployment. In A.B. Atkinson & J. Hill (Ed.) Exclusion, employment and opportunity, case paper 4 pp. 1–20. Centre for the Analysis of Social Exclusion, London School of Economics. Ball, G.D.C., Lenk, J.M., Barbarich, B.N., et al. (2008) Overweight children and adolescents referred for weight management: are they meeting lifestyle behaviour recommendations? Applied Physiology, Nutrition, and Metabolism 33, 936–945. Burton, P & Phipps, S. (2009) Families, time and well-being in Canada draft. Cole, T.K., Bellizzi, M.C., Flegal, K.M., & Dietz, W.H. (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320, 1240–1243. Elgar, F.J., Roberts, C., Tudor-Smith, C., & Moore, L. (2005) Validity of self-reported height and weight and predictors of bias in adolescents. Journal of Adolescent Health 37(5), 371–375. Janssen, I., Katzmarzyk, P.T., Boys, W.F., King, M.A., & Picket, W. (2004) Overweight and obesity in Canadian adolescents and their associations with dietary habits and physical activity patterns. Journal of Adolescent Health 35, 360–367. Lin, B.H., Huang, C.L., & French, S.A. (2004) Factors associated with women’s and children’s body mass indices by income status. International Journal of Obesity 28, 536–542. Luxembourg Income Study (LIS) (2009) Key Figures, (November 16, 2009). Micklewright, J. (2002) Social exclusion and children: a European view for a US debate. Case paper 51. Centre for Analysis of Social Exclusion. London School of Economics. O’Dea, J. (2003) Differences in overweight and obesity among Australian schoolchildren of low and middle-high socioeconomics status. Medical Journal of Australia 179, 289. O’Dea, J. (2008) Gender, ethnicity, culture and social class influences on childhood obesity among Australian schoolchildren: implications for treatment, prevention and community education. Health and Social Care in the Community 16(3), 282–290. O’Dea, J. (2006) Self-concept, self-esteem and body weight in adolescent females. Journal of Health Psychology 22(4), 599–611. Oliver, L.N. & Hayes, M.V. (2005) Neighbourhood socio-economic status and the prevalence of overweight Canadian children and youth. Canadian Journal of Public Health 96(6), 415–420. Phipps, S., Burton, P., Lethbridge, L., & Osberg, L. (2005) Poverty and the extent of child obesity in Canada, Norway and the United States. Obesity Reviews 7, 5–12. Phipps, S., Lethbridge, L., & Burton, P. (2006) Long-run consequences of parental paid work hours for child overweight status in Canada. Social Science and Medicine 62, 977–986.

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Picot, G. (2004) The deteriorating economic welfare of immigrants and possible causes. Statistics Canada Analytical Studies Branch Research Paper Series, No. 222, Catalogue No. 11F0019. Rosmond, R. (2005) Role of stress in the pathogenesis of the metabolic syndrome. Psychoneuroendocrinology 30, 1–10. Shields, M. (2005) Measured obesity: overweight Canadian children and adolescents. Statistics Canada. Cat No. 82-620-MWE2005001. Statistics Canada (2006a) Canada Community Health Survey. Integrated Derived Variable and Grouped Variable Specifications, viewed November 9, 2009, 〈〉 Statistics Canada (2006b) Public Use Microdata File (PUMF) User Guide, Canada Community Health Survey, viewed November 9, 2009, Thompson, O.M., Ballew, C., Renicow, K., et al. (2004)Food purchased away from home as a predictor of change in BMI z-score among girls. International Journal of Obesity 28, 282–289. Wang, Y. & Zhang, Q. (2006) Are American children and adolescents of low socioeconomic status at increased risk of obesity? Changes in the association between overweight and family income between 1971 and 2002. American Journal of Clinical Nutrition 84, 707–716. Notes: (Appendix Table 4.1) Means of explanatory variables used in logit regressions Girls

Boys

Low family income (bottom quintile of Canadian income distribution) (%)

22.3

19.8

Child age 15 to 17 (%)

52.2

50.2

Child non-white (%)

16.2

17.3

Child an immigrant (%)

8.1

9.2

Highest parental education less than high school (%)

3.3

4.3

Highest parental education post-secondary diploma or degree (%)

80.2

78.1

Atlantic (%)

8.0

7.8

Quebec (%)

23.8

22.4

West (%)

27.7

28.0

Child has activity limitation (%)

18.7

17.2

Daily energy expenditure (kcal/kg/day)

3.43 4.76 (3.19) (4.34)

Child feels a ‘very strong’ sense of belonging to local community (%)

78.2

77.3

Number of observations

3191

3422

Nutrition sub-module (sub-sample from PEI, Ontario, Alberta and BC only)

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Low family income and the overweight status of Canadian adolescents

Girls

Boys

Daily servings of fruits/vegetables

5.39 5.17 (2.67) (2.96)

Number of observations

1689

1881

Family sometimes/often could not afford a balanced diet (%)

6.9

6.2

Number of observations

2566

2814

No paid hours (%)

52.1

57.3

0 to 9 hours per week (%)

12.0

9.8

10 to 19 hours per week (%)

25.2

20.1

20+ hours per week (%)

10.7

12.8

Not in school (%)

6.7

6.9

Number of observations

1580

1651

Food security sub-module (sub-sample from NS, PEI, QC, ON, AB, BC)

Paid work sub-module (sub-sample of 15 to 17 year old youth)

(1) We have experimented with using national income deciles, including all five quintiles and including simply a measure of (the log of) family income. In all cases, we find the same pattern of results, so choose to focus on the most parsimonious specification to simplify presentation. (2) Indeed, some recent research points out that the connection between socioeconomic status and obesity might differ by ethnicity (e.g., Wang and Zhang, 2006). (3) In past work (Phipps et al., 2006), we found, for younger children, a correlation between maternal paid work hours and the overweight status of children aged 6 to 11. A weakness of the CCHS is that we are unable to control for parental paid hours in this study. (4) These data are from a sub-set of four provinces rather than the full Canadian sample. (5) These data make use of a sub-module of the CCHS in which six provinces participated (PEI, Nova Scotia, Quebec, Ontario, Alberta, and BC). (6) In pooled boy/girl models, girls are significantly less likely than the boys to be either obese or overweight. (7) Morbid obesity could in itself be an activity limitation. (8) A possible interpretation of this correlation is that overweight girls are less likely to be hired?

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Issues of teacher training in the prevention of eating disorders and childhood obesity in schools

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Issues of teacher training in the prevention of eating disorders and childhood obesity in schools Zali Yager

DOI:10.1093/acprof:oso/9780199572915.003.0005

Abstract and Keywords This chapter provides an overview of the many issues that surround teacher training for childhood obesity and eating disorder prevention, including issues of professional knowledge, personal attitudes and behaviours, and bias against overweight. A discussion of how best to train both pre-service and practicing teachers to combine efforts for the prevention of eating disorders and obesity in schools follows.

Keywords: teachers, education, schools, eating disorders, obesity, children

Chapter summary This chapter provides an overview of the many issues that surround teacher training for childhood obesity and eating disorder prevention, including issues of professional knowledge, personal attitudes and behaviours, and bias against overweight. A discussion of how best to train both pre-service and practising teachers to combine efforts for the prevention of eating disorders and obesity in schools follows.

Introduction Schools are recognized as appropriate settings for health promotion, and for the prevention of a broad spectrum of weight problems including eating disorders and child obesity. They allow access to a large number of individuals at a developmentally appropriate age (NeumarkSztainer, 1996; O’Dea & Abraham, 2000; O’Dea, 2000; Smolak et al., 1998), and opportunities for both a formal and informal curriculum that can be reinforced using the Health Promoting Schools Framework (Neumark-Sztainer, 1996; O’Dea & Maloney, 2000). A wide range of school-

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Issues of teacher training in the prevention of eating disorders and childhood obesity in schools

based programmes aimed at reducing these weight issues have been implemented but have had little impact, and these problems still persist around the world. One of the main reasons for the modest improvements gained from prevention programmes in schools may be due to the lack of training given to the teachers who are implementing them. Very few studies have investigated the personal and professional capabilities of school teachers and other school personnel that deliver or support such programmes (Yager & O’Dea, 2005). Primary school teachers receive little or no training in nutrition or prevention techniques, and they consistently report a lack of knowledge as a barrier to implementing health promotion and prevention programmes (Neumark-Sztainer et al., 1999b; Stang et al., 1997). The capacity of Health and Physical Education (HPE) teachers in this area may also be restricted by limited knowledge, personal susceptibility to dieting and disordered eating and exercise behaviours, and a ‘healthist’ attitude (O’Dea & Abraham, 2001; Yager, 2008). Why then, do we assume that these professionals are capable of modelling healthy food choices and implementing education programmes to prevent eating disorders and obesity? What can we do to prepare them, personally and professionally, for this critical role? School professionals’ knowledge about weight, nutrition, and obesity Knowledge about eating disorders, nutrition, and obesity is often assumed, but not guaranteed among those who are most likely to be involved in the prevention of childhood obesity and eating (p.57) disorders in schools. Nutrition knowledge among prospective teachers is known to be limited (Rossiter et al., 2007; Yager, 2008) and their personal food behaviours and classroom food practices reflect this low level of knowledge (Kubik et al., 2002; Rossiter et al., 2007). Teachers receive very little training in nutrition and the physiology of weight control and may therefore possess many food and weight loss myths and misconceptions and pass them on to their students. This low level of training and preparation means that teachers may be no more knowledgeable than the general public in regard to the determinants of height and weight, and the understanding of the complex nature and causes of weight issues. Teachers (Greenleaf & Weiller, 2005; Neumark-Sztainer et al., 1999a), school nurses (Price et al., 1987b), and elementary school principals (Price et al., 1987a) incorrectly identify individual behaviours such as over-consumption and inactivity as the only causes, or major causes of obesity (NeumarkSztainer et al., 1999a; Price et al., 1987b). Although they receive more training in health, nutrition, and human development, HPE teachers have also been shown to have low levels of knowledge about the causes of obesity (Cho & Fryer, 1974; Greenleaf & Weiller, 2005; Irwin et al., 2003; O’Dea & Abraham, 2001; Savage, 1995; Thompson et al., 2006). In a study of 105 current physical education teachers in the USA, only 50% correctly reported that heredity was a factor contributing to obesity in young people, whereas 99% agreed that poor eating behaviours were to blame (Greenleaf & Weiller, 2005). This leads to a negative, ‘victim blaming’ attitude towards overweight and obese people and may contribute to weight bias and the stigmatization of big children and their parents (Neumark-Sztainer et al., 1999a; O’Dea, 2004; Schwartz et al., 2003). Teacher training rarely prepares teachers with knowledge and skills in prevention, and many current professionals request further training in this area. High proportions of high school

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Issues of teacher training in the prevention of eating disorders and childhood obesity in schools

science, health, physical education, and home economics teachers show interest in staff training to improve their knowledge and skills in the prevention of weight-related disorders (NeumarkSztainer et al., 1999b; Stang et al., 1997; Yager, 2003). Lack of training (53%) and lack of educational materials (42%) have also been identified as major barriers to the implementation of effective obesity prevention programmes in schools (Stang et al., 1997). It is clear that school professionals are keen to be involved in the school-based prevention of childhood obesity and eating disorders as long as they are provided with adequate training and resources. Pre-service teacher training and professional development programmes should aim to prepare teachers for the difficult task of dealing with weight issues in schools; and an important part of this training will be the clarification of their preventive role.

Confusion of the role of schools and teachers in childhood obesity prevention The role of teachers and schools in relation to childhood obesity and eating disorders needs to be clearly defined. Research among all levels of the school administration and teaching staff has found that school professionals consistently identify the school as a place for the treatment of childhood obesity and weight disorders. Although schools are valuable settings for health promotion, and prevention of these weight issues, they are not the place for treatment, and school professionals are not adequately trained for this role (O’Dea, 2004). Early studies among school professionals found that teachers and school health workers (Neumark-Sztainer et al., 1999b), elementary school principals (Price et al., 1987a), and school nurses (Price et al., 1987b) believed that schools should play a role in the treatment of childhood obesity. The majority of participants also indicated that schools were not currently competent in this role (Neumark-Sztainer et al., 1999b; Price et al., 1987a). These attitudes may come from the administrative level, as one study found that school principals identified the school nurse (77%), school counsellor (69%), and the physical education teacher (59%) as those who should play (p.58) a major role in the treatment of obesity in schools (Price et al., 1987a). Alternately, physical education teachers state that they are the ones who should play the major role in the treatment of obesity (95%), as well as school nurses (94.3%), school counsellors (76.2%), and other school teachers (65.7%) (Greenleaf & Weiller, 2005). In that study, 61% of the current physical education teachers also indicated that physical education classes that are designed for, and available only to, overweight students should be available in all schools (Greenleaf & Weiller, 2005). These attitudes are concerning as they indicate that PE teachers may feel as though they are responsible for, or capable of, treating childhood obesity even though most seem to have very little knowledge of the causes of overweight. Weight bias and stigmatization of big children and their parents Negative attitudes towards overweight people are well reported (Puhl & Brownell, 2001; Puhl & Heuer, 2009) and there is evidence to suggest that levels of weight bias are worsening (Andreyeva et al., 2008; Latner & Stunkard, 2003). Explicit and implicit attitude tests consistently show that the general public, including those who are overweight themselves, have negative attitudes towards overweight and obesity (Brandsma, 2005; Teachman & Brownell, 2001). Training and experience in health fields and obesity research does not eliminate this bias and an interest in health may lead to increased negative attitudes towards overweight (Berryman et al., 2006; Teachman & Brownell, 2001).

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Issues of teacher training in the prevention of eating disorders and childhood obesity in schools

Weight bias is common in schools and may come from both students and teachers. A large proportion of adolescents (30% of girls and 24% of boys) report current weight-based teasing from their peers regardless of their actual weight status (Eisenberg, 2003). Anti-fat prejudice from a teacher was also reported by 32% of women in a retrospective study (Puhl & Brownell, 2006). Perceived or actual bias and discrimination from teachers and students is known to have many negative effects on student’s well-being (Eisenberg, 2003), and may also make overweight students less likely to participate in activities that draw additional attention to their weight such as physical education (Bauer et al., 2004). Physical education teachers are responsible for students at a time when they are most vulnerable to weight-based teasing (Fox & Edmunds, 2000) and physical education teachers are known to possess significant weight bias (Greenleaf & Weiller, 2005; Greenleaf et al., 2008b; Moore, 2008; O’Brien & Hunter, 2006). These levels of anti-fat attitudes are consistent with those found in exercise science (Chambliss et al., 2004) and dietetics students (Berryman et al., 2006; Oberrieder et al., 1995), and registered dieticians (McArthur & Ross, 1997). These negative attitudes were found to be highest among male pre-service physical education teachers and students in their first year of undergraduate study (Moore, 2008). Even if levels of weight bias are not significantly higher among pre-service and current physical education teachers (Greenleaf & Weiller, 2005; Greenleaf et al., 2008a), they are still of concern due to the important role that these teachers play in encouraging healthy behaviours. Physical education is rife with situations where bias, stigma, and weight-based teasing may occur. Overweight youth often report that weight-based teasing is ignored by PE teachers (Fox & Edmunds, 2000). In some cases, weight-based teasing or insensitive comments may be unintentional, and may not be recognized as hurtful by the perpetrator or the teacher who is responsible but can still cause harm to the victim (Eisenberg, 2003). However if teachers themselves have high levels of anti-fat bias then they may not identify and stop weight-based teasing when it occurs in their classes, or they may inadvertently or intentionally make inappropriate comments. Not surprisingly, those students who have experienced weight-based criticism during physical activity report less enjoyment of, and less participation in, physical activity, sport, and exercise (p.59) (Faith et al., 2002). Overweight students may therefore aim to avoid physical education by absence from class or notes from parents to excuse their participation. This further perpetuates the stereotype that overweight people are lazy and may prevent them from developing the fundamental motor skills and experience in physical activity and sports that would contribute to life-long physical activity patterns. It is important to remember the potential impact of weight bias from peers, teachers, and administrators when designing interventions (O’Dea, 2004; Rukavina & Li, 2008) and in developing training programmes for teachers. Developing appropriate attitudes towards obesity among teachers and other school professionals is crucial in the effectiveness of prevention programmes and physical education (O’Dea, 2000; O’Dea & Abraham, 2001; Piran, 1998; Stewart, 1998). Pre-service and in-service training should aim to reduce the existence of this bias and to help pre-service teachers to develop the skills and techniques required to identify, prevent, and manage weight-based teasing in their classes and in the playground.

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Issues of teacher training in the prevention of eating disorders and childhood obesity in schools

Personal eating and exercise behaviours of school professionals Those school professionals who are most interested in dealing with childhood obesity and eating disorders in schools may have this interest due to their own personal body image and eating problems. This was demonstrated in the author’s study of school professionals (including health and PE teachers, school counsellors, and other teachers) attending an ‘Eating Disorders in Schools’ professional development day, as the majority of attendees were female, the majority (72.9%) were dieting and a large proportion (25%) reported that they believed that they had experienced an eating disorder (Yager, 2003). The Health and Physical Education teachers attending this conference were significantly more likely than the others to desire thinness, be dieting, and report a history of eating and exercise disorders (Yager, 2003). Individuals in food and exercise related career paths are known to be at risk for engaging in disturbed dieting and exercise behaviours to the same or higher extent as the general population (Kinzl et al., 1999; McArthur & Howard, 2001; O’Dea & Abraham, 2001; Palmquist-Fredenberg et al., 1996; Worobey & Schoenfeld, 1999). The majority of empirical research has focused on dietetics students and trained dieticians, with studies reporting that 24% of dietetics majors in the USA and 25% in Austria exhibited characteristics of anorexia nervosa (Drake, 1989; Kinzl et al., 1999). Health and physical education teachers may be a similar population who are at risk of eating and exercise disorders. O’Dea and Abraham (2001) found that among female trainee home economics and physical education teachers, 29% reported using excessive exercise, 19% used starvation, 22% inducing vomiting, 19% used laxatives, and 7% used smoking to control their weight (O’Dea & Abraham, 2001). Problematic attitudes and behaviours were also found among the males, as 29% desired weight gain to ‘bulk up’ their muscles and some reported disordered eating behaviours (O’Dea & Abraham, 2001). Another similar population of trainee HPE teachers were also found to have a significantly higher prevalence of body dissatisfaction, dieting, disordered eating behaviours, and exercise disorders than a control group of university students who were not enrolled in degrees related to food or exercise (Yager & O’Dea, 2009). In particular, 41% of PE males and 32% of PE females were classified as having an exercise disorder according to the OEQ compared with 15% and 14% respectively in the non PE group (Yager & O’Dea, 2009). A New Zealand study found that female trainee HPE teachers scored significantly higher than psychology students on measures of dieting and bulimia nervosa (BN) and they had significantly lower global self-esteem (O’Brien & Hunter, 2006). Finally, 18% of male physical education majors in an American study were at risk for severe body dissatisfaction and they desired extremely high levels of muscularity (Olsen et al., 2009). (p.60) Empirical research is yet to confirm whether those with a preoccupation with diet and exercise are attracted to university degrees that involve food and exercise, or if these problems develop as a result of their training. The high prevalence of eating and exercise problems, in first-year students may indicate the former (Yager & O’Dea, 2009). A preoccupation with food and exercise is known to be characteristic of individuals with eating disorders (Larson, 1989; Worobey & Schoenfeld, 1999) and it has been suggested that this may also cause them to gravitate towards careers that are food and exercise related (Crockett & Littrell, 1985; Reinstein et al., 1992; Sours, 1980). In their Austrian study, Kinzl and colleagues (1999) reported that 14%

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Issues of teacher training in the prevention of eating disorders and childhood obesity in schools

of the dieticians studied had chosen their career path partly due to their own preoccupation with food and exercise. Students may also develop disordered eating and exercise attitudes and behaviours during their training as a result of social norms and pressure to ‘look the part’ of a health and PE teacher. Those in food and exercise related career paths are exposed to similar socio-cultural pressures as other adults, yet the nature of their career may mean that their professional capabilities are assessed by their personal adherence to the thin or muscular ideal. These individuals may also have a self–formed and socially reinforced idea of what a health and fitness professional should look like, which may lead them to engage in excessive exercise behaviours and dangerous weight loss techniques (Brownell et al., 1992; Phillips & Drummond, 2001). A study of fitness leaders has shown the strong internal drive to advertise professional competence through their personal appearance, as one fitness leader commented: ‘In this industry you have to look the part. I mean, there’s no point in having someone who’s overweight as a fitness leader. It’s not the right image. You’ve got to look fit’ Anonymous Participant. (Phillips & Drummond, 2001, p. 99) A similar attitude and situation is assumed and anecdotally reported for health and physical education teachers. The burden of having to be an appropriate role model and needing to ‘look like a PE teacher’ may drive some students to use disordered eating behaviours and excessive exercise, as 97.1% of current PE teachers agreed that PE teachers should be appropriate role models by maintaining ‘normal weight’ (Greenleaf & Weiller, 2005). Researchers have confirmed the potential for modelling positive health behaviours by physical education teachers (Cardinal, 2001). However, little has been done to investigate the modelling of undesirable and inappropriate behaviours, which may cause harm such as the disordered eating and exercise behaviours that are required to maintain this slim and ‘fit’ ideal. There is anecdotal evidence that indicates that it may be possible for physical education teachers to be transferring strong attitudes about the importance of thinness, and the use of food and exercise to gain the slim ideal (O’Dea & Abraham, 2001; O’Dea, 2002; Rutz, 1993; Stewart, 1998). Being immersed in a culture of fitness and health, and being surrounded by people who are similarly involved in exercise and weight control may also increase disordered eating and exercise behaviours through social norms and reinforcement (Phillips & Drummond, 2001). For example, it may become ‘normal’ among groups of trainee HPE teachers to work out at the gym several times in a day, and restrict foods (even though they already appear to be slim and muscular) just because everyone else is doing it. The internal social norms for trainee PE teachers may therefore become very focused on the body, food, and exercise, in a similar manner that has been observed among adolescent girls (Eisenberg et al., 2004), ballet dancers (Hamilton et al., 1985), and in sororities (Allison & Park, 2004; Crandall, 1988; Schulken et al., 1997). To add external pressure, a physical educator’s external appearance is often used to indicate both their perceived fitness and their professional competence. A study in the USA found that physical education teachers who were less academically qualified, but appeared to be physically

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Issues of teacher training in the prevention of eating disorders and childhood obesity in schools

fit, were deemed more employable than one who was 10 or 20 pounds overweight (Bandura, 1986; Melville & Cardinal, 1997). PE teachers who appear to be physically fit were deemed by students to be more (p.61) likable and more competent than those that were overweight (Melville & Maddalozzo, 1988). In that study, the PE teacher who was normal weight also had a greater positive influence on high school students’ learning and behavioural intention to exercise (Melville & Maddalozzo, 1988). Implications for teacher training and re-training Pre-service teachers require training that enhances their knowledge, improves their attitudes towards overweight students, and reduces their vulnerability to eating and exercise disorders. Practising teachers may also need this sort of education in order to re-train them in a more positive approach to teaching about food, exercise, and weight, and to reduce their weight bias. Professional development is also needed to correct their misconceptions of their role as one of treatment, and to advise them of appropriate referral procedures. A summary of recommendations for pre-service teacher training and professional development is presented in Table 5.1. The author has implemented a successful programme to improve the personal health behaviours of trainee health and physical education teachers utilizing elements as described in Table 4.1(Yager & O’Dea, In Press). This resulted in significant improvements in self-esteem, body dissatisfaction, and drive for muscularity among the male participants. Females improved significantly on drive for thinness and excessive exercise. The improvements in drive for thinness Table 5.1 Summary of recommendations for pre-service teacher training and professional development for the prevention of obesity and body image problems Recommendations of necessary content

Possible teaching and learning activities

Physiology ◆ Determinants of height and weight

Didactic lectures about the physiology of diet and exercise, and complex nature and causes of overweight. Problem based learning tasks utilizing overweight as an example in a way that leads to discovery of genetic or hormonal causes of overweight and obesity.

◆ Causes of overweight

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Issues of teacher training in the prevention of eating disorders and childhood obesity in schools

Recommendations of necessary content

Possible teaching and learning activities

Clarification of important role in prevention through appropriate education and developing healthy attitudes and life-long physical activity. Information about appropriate referral pathways for suspected eating disorders and risk factors for overweight. Collaborative learning activities to demonstrate models of ◆ Prevention science behaviour change including a jigsaw activity to have students become an ‘expert’ on one of the models, and then teach others in ◆ Social models of their group. Students apply models to health promotion examples. health Show examples of inappropriate activities and initiatives (e.g. ◆ Health promoting Having guest speakers or showing videos by those who have recovered from eating disorders, singling out overweight children schools for special lunchtime diet and exercise programmes) and explain why they are dangerous and ineffective according to what we know about health psychology and health promotion. Follow with a discussion of safe and effective activities and health promotion programmes. Students develop a Health promoting school project from case studies (including global examples) or implement in a local school.

Health psychology and health promotion ◆ Models of behaviour change

Personal health behaviours ◆ Model appropriate teaching about diet, nutrition, and exercise in a positive way ◆ Improve personal body image, eating and exercise disorders Weight bias ◆ Attitudes towards overweight ◆ Ability to identify, prevent and deal with weight based teasing.

Build self-esteem using a positive classroom attitude and activities such as Strength Cards, warm fuzzies, or the hand outline activity (See O’Dea, 2007). Model appropriate teaching about diet, nutrition, and exercise in a positive way without a ‘healthist’ attitude. Use media literacy and cognitive dissonance techniques to reduce the internalization of the thin and muscular ideals (See Stice et al., 2008) in the teachers and model their use for schools. Discuss importance of having appropriate attitudes and behaviours so that students can view teachers as appropriate role models for healthy attitudes and behaviours overall, not just in appearance, diet, and exercise. Use evidence from scientific journals to have a debate about whether you can be ‘fat and fit’. Discuss the variability of scientific claims about an ‘obesity epidemic’ and the media’s responsibility for development of this phenomenon. Watch the video ‘Weight Bias at Home and School’ from the Yale Rudd Centre available on their website (http:// www.yaleruddcenter.org). Other authors have implemented a Service learning project among Kinesiology students where they were given information on antifat bias, health related fitness and barriers to healthy lifestyle in addition to hands on experience with 4th and 5th grade students. The level of individual blame for overweight and obesity levels was reduced at post test (Rukavina et al., 2008).

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Issues of teacher training in the prevention of eating disorders and childhood obesity in schools

Recommendations of necessary content

Possible teaching and learning activities

Stress the importance of keeping up to date with scientific knowledge and to present information without bias or generalization. Use case studies of instances of weight bias from teachers and students to have students develop a strategic response and ideas for prevention. ◆ Prevention of Brainstorm examples of problems around weight from their own weight based teasing schooling, e.g. PE change rooms, fitness testing, swimming, etc. and opportunities for classroom management to avoid issues in ◆ Classroom those areas. management procedures

Professional responsibility ◆ Maintaining professional knowledge

(p.62) and drive for muscularity were encouraging given that internalization of these variables is a known predictor of eating disorder pathology according to the Dual Pathway Model (Stice & Agras, 1998). This idea of a personal and professional approach fits well with the literature on higher education pedagogy and is easily incorporated into the course structure of teacher training programmes. More details regarding this programme are available from the author and details of a subsequent programme for trainee primary school teachers is also available (Yager, 2009).

(p.63) Conclusion In order for future prevention of childhood obesity to be successful, pre-service and ongoing training for school professionals is urgently required. This training must increase their knowledge of nutrition, eating disorders, obesity, and preventive techniques. Personal approaches to teacher preparation that utilize behaviour change techniques and a health promotion approach are also likely to improve the personal weight-related attitudes and behaviours of school professionals. Finally, teacher training programmes should address weight bias among school professionals. These coordinated measures are required in order to fully utilize teachers as potential change agents in preventing childhood obesity and eating disorders and promoting the health of our young people. References Bibliography references: Allison, K.C. & Park, C.L. (2004) A prospective study of disordered eating among sorority and nonsorority women. International Journal of Eating Disorders 35, 354–358. Andreyeva, T., Puhl, R., & Brownell, K.D. (2008) Changes in perceived weight discrimination among Americans, 1995–1996 through 2004–2006. Obesity 16, 1129–1134. Bandura, A. (1986) Social foundations of thought and action: A social cognitive theory. Englewood Cliffs: Prentice Hall.

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Bauer, K.W., Yang, W., & Bryn Austin, S. (2004) How can we stay healthy when you’re throwing all of this in front of us? Findings from focus groups and interviews in middle schools on environmental influences on nutrition and physical activity. Health Education & Behavior 31, 34–48. Berryman, D. E., Dubale, G.M., Manchester, D.S., & Mittelstaedt, R. (2006) Dietetics students possess negative attitudes toward obesity similar to nondietetics students. Journal of the American Dietetic Association 106, 1678–1682. Brandsma, L.L. (2005). Physician and patient attitudes towards obesity. Eating Disorders 13, 201–211. Brownell, K.D., Rodin, J., & Wilmore, J.H. (1992) Eating, body weight and performance in athletes: An introduction. In K.D. Brownell, J. Rodin, & J.H. Wilmore (Ed.), Eating, body weight and performance in athletes: Disorders of modern society pp. 3–16. Philadelphia: Lea & Fabinger. Cardinal, B.J. (2001) Role modelling attitudes and physical activity and fitness promoting behaviours of HPERD professionals and pre professionals. Research Quarterly for Exercise and Sport 72, 84–90. Chambliss, H.O., Finley, C.E., & Blair, S.N. (2004) Attitudes toward obese individuals among exercise science students. Medicine and Science in Sports and Exercise 36(3), 468–474. Cho, M. & Fryer, B.A. (1974) Nutritional knowledge of collegiate physical education majors. Journal of the American Dietetic Association 65, 30–34. Crandall, C.S. (1988) Social contagion of binge eating. Journal of Personal and Social Psychology 55, 588–598. Crockett, S.J. & Littrell, J.M. (1985) Comparison of eating patterns between dietetic and other college students. Journal of Nutrition Education 17, 47–50. Drake, M.A. (1989) Symptoms of anorexia nervosa in female university dietetic majors. Journal of the American Dietetic Association 89(1), 97–99. Eisenberg, M. (2003) Associations of weight-based teasing and emotional well-being among adolescents. Archives of Pediatrics and Adolescent Medicine 157, 733–738. Eisenberg, M.E., Neumark-Sztainer, D., Story, M. & Perry, C. (2004) The role of social norms and friends’ influences on unhealthy weight-control behaviors among adolescent girls. Social Science & Medicine 60(6), 1165–1173. Faith, M.S., Leone, M.A., Ayers, T.S., Moonseong, H., & Pietrobelli, A. (2002) Weight criticism during physical activity, coping skills, and reported physical activity in children. Pediatrics 110, e23–e33.

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Fox, K.R. & Edmunds, L.D. (2000) Understanding the world of the ‘fat kid’: can schools help provide a better experience? Reclaiming Children and Youth 9(3), 177–181. Greenleaf, C., Martin, S.B., & Rhea, D. (2008a) Fighting fat: how do fat stereotypes influence beliefs about physical education? Obesity 10(Supplement 2), S53–S61. Greenleaf, C. & Weiller, K. (2005) Perceptions of youth obesity among physical educators. Social Psychology of Education 8, 407–423. Hamilton, L.H., Brooks-Gunn, J., & Warren, M.P. (1985) Sociocultural influences on eating disorders in professional female ballet dancers. International Journal of Eating Disorders 4(4), 465–477. Irwin, C.C., Symons, C.W., & Kerr, D.L. (2003) The dilemmas of obesity: how can physical education help? The Journal of Physical Education, Recreation & Dance 74(6), 33–40. Kinzl, J., Traweger, C., Trefalt, E., Mangweth, B., & Biebl, W. (1999). Dieticians: are they a risk group for eating disorders? European Eating Disorders Review 7, 62–67. Kubik, M.Y., Lytle, L.A., Hannan, P.J., Story, M., & Perry, C.L. (2002) Food related beliefs, eating behavior, and classroom food practices of middle school teachers. The Journal of School Health 72(8), 339–346. Larson, B. (1989) The new epidemic: ethical implications for nutrition educators. Journal of Nutrition Education 21, 101–103. Latner, J.D. & Stunkard, A. (2003) Getting worse: the stigmatization of obese children. Obesity Research 11, 452–456. McArthur, A. & Howard, A. (2001) Dietetics majors’ weight-reduction beliefs, behaviours, and information sources. Journal of American College Health 49, 175–184. McArthur, L.A. & Ross, J. (1997) Attitudes of registered dietitians toward personal overweight and overweight clients. Journal of the American Dietetic Association 97(1), 63–66. Melville, D.S. & Cardinal, B.J. (1997) Are overweight physical educators at a disadvantage in the labor market? A random survey of hiring personnel. The Physical Educator 54, 216–221. Melville, D.S. & Maddalozzo, J.G.F. (1988) The effects of a physical educator’s appearance of body fatness on communicating exercise concepts to high school students. Journal of Teaching in Physical Education 7, 343–352. Moore, S. (2008) Pre-service PDHPE teachers’ perceptions of their role in the prevention of childhood obesity. Sydney: University of Sydney. Neumark-Sztainer, D. (1996) School based programs for preventing eating disturbances. Journal of School Health 66, 64–71.

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Neumark-Sztainer, D., Story, M., & Harris, T.R. (1999a) Beliefs and attitudes about obesity among teachers and school health care providers working with adolescents. Journal of Nutrition Education 31(1), 3–9. Neumark Sztainer, D., Story, M., & Coller, T. (1999b) Perceptions of secondary school staff toward the implementation of school-based activities to prevent weight-related disorders: a needs assessment. American Journal of Health Promotion 13(3), 153–156. O’Brien, K. & Hunter, J. (2006) Body esteem and eating behaviours in female physical education students. Eating and Weight Disorders 11, e57–e60. O’Dea, J. (2000) School based interventions to prevent eating problems: first do no harm. Eating Disorders 8, 123–130. O’Dea, J. (2002) Can body image education programs be harmful to adolescent females? Eating Disorders 10, 1–13. O’Dea, J. (2004) Prevention of child obesity: first, do no harm. Health Education Research 20(2), 259–265. O’Dea, J. & Abraham, S.F. (2000) Improving the body image, eating attitudes, and behaviours of young male and female adolescents: a new educational approach that focuses on self esteem. International Journal of Eating Disorders 28, 43–57. O’Dea, J. & Abraham, S.F. (2001) Knowledge, beliefs, attitudes and behaviours related to weight control, eating disorders, and body image in Australian trainee home economics and physical education teachers. Journal of Nutrition Education 33, 332–340. O’Dea, J. & Maloney, D. (2000) Preventing eating and body image problems in children and adolescents using the Health Promoting Schools Framework. The Journal of School Health 70(1), 18–22. Oberrieder, H., Walker, R., Monroe, D., & Adeyanju, M. (1995) Attitude of dietetics students and registered dietitians toward obesity. Journal of the American Dietetic Association 95(8), 914– 916. Olsen, M.S., Esco, M.R., & Williford, H. (2009) Body image concerns in college-aged male physical education students. Physical Educator 66(1), 45–55. Palmquist-Fredenberg, J., Berglund, P., & Dieken, H. (1996) Incidence of eating disorders among selected female university students. Journal of the American Dietetic Association 96, 64– 66. Phillips, J. & Drummond, M. (2001). An investigation into the body image perception, body satisfaction and exercise expectations of male fitness leaders: implications for professional practice. Leisure Studies 20, 95–105.

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Piran, N. (1998) A participatory approach to the prevention of eating disorders in a school. In W. Vandereycken & G. Noordenbos (Ed.) The prevention of eating disorders. pp. 173–186. London: The Athlone Press. Price, J.H., Desmond, S.M., Ruppert, E.S., & Stelzer, C.M. (1987a) School nurses’ perceptions of childhood obesity. Journal of School Health 57(8), 332–336. Price, J.H., Desmond, S.M., & Stelzer, C.M. (1987b) Elementary school principals’ perceptions of childhood obesity. Journal of School Health 57(9), 367–370. Puhl, R. & Brownell, K.D. (2001) Bias, discrimination and obesity. Obesity Research 9(12), 788– 805. Puhl, R. & Brownell, K.D. (2006) Confronting and coping with stigma: an investigation of overweight and obese adults. Obesity 14(10), 1802–1816. Puhl, R. & Heuer, C.A. (2009). The stigma of obesity: A review and update. Obesity 17, 941–964. Reinstein, N., Koszewski, W., Chamberlain, B., & Smith-Johnson, C. (1992) Prevalence of eating disorders among dietetics students: does nutrition education make a difference? Journal of the American Dietetic Association 92, 949–954. Rossiter, M., Glanville, T., Taylor, J., & Blum, I. (2007) School food practices of prospective teachers. Journal of School Health 77(10), 694–700. Rukavina, P.B. & Li, W. (2008) School physical activity interventions: do not forget about obesity bias. Obesity Reviews, 9, 67–75. Rukavina, P.B., Li, W., & Rowell, M.B. (2008) A service learning based intervention to change attitudes towards obese individuals in kinesiology pre-professionals. Social Psychology of Education 11, 95–112. Rutz, S. (1993) Nutrition educators should practice what they teach. Journal of Nutrition education 25(2), 87–88. Savage, M.P. (1995) Perceptions of childhood obesity of undergraduate students in physical education. Psychological reports 76(3), 1251–1259. Schulken, E.D., Pinciaro, P.J., Sawyer, R.G., Jensen, J.G., & Hoban, M.T. (1997) Sorority women’s body size perceptions and their weight related attitudes and behaviors. Journal of American College Health 46(2), 69–74. Schwartz, M., O’Neal Chambliss, H., Brownell, K., Blair, S., & Billington, C. (2003) Weight bias among health professionals specializing in obesity. Obesity Research 11, 1033–1039. Smolak, L., Levine, M., & Schermer, F. (1998) A controlled intervention of an elementary school primary prevention program for eating problems. Journal of Psychosomatic Research 44, 339– 353.

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Sours, J. (1980) Starving to death in a sea of objects: The anorexia nervosa syndrome. New York: J Aronson. Stang, J., Story, M., & Kalina, B. (1997) School-based weight management services: perceptions and practices of school nurses and administrators. American Journal of Health Promotion 11(3), 183–185. Stewart, A. (1998) Experience with a school-based eating disorders prevention program. In W. Vandereycken & G. Noordenbos (Ed.) The prevention of Eating Disorders pp. 99–136. London: The Athlone Press. Stice, E. & Agras, W.S. (1998) Predicting onset and cessation of bulimic behaviours during adolescence: a longitudinal grouping analysis. Behaviour Therapy 29, 257–276. Teachman, B.A. & Brownell, K. (2001) Implicit anti-fat bias among health professionals: is anyone immune? International Journal of Obesity 25, 1525–1531. Thompson, A., Smith, C., Hunt, B., & Sharp, C.W. (2006) Health teacher perceptions and teaching practices regarding disordered eating behaviors in high school students. American Journal of Health Studies 21(3), 158–168. Worobey, J. & Schoenfeld, D. (1999) Eating disordered behaviour in dietetics students and students in other majors. Journal of the American Dietetic Association 99, 100–104. Yager, Z. (2003) Body image, dieting and disordered eating behaviour in school professionals dealing with body image issues and eating problems. Honours Thesis. (University of Wollongong, Wollongong). Yager, Z. (2008) Body image, body dissatisfaction, dieting and disordered eating and exercise behaviours of trainee physical education teachers: investigation and intervention. Doctoral Thesis. (University of Sydney, Sydney). Yager, Z. (2009) Developing wellbeing in first year pre-service teachers: reflections on a pilot of a personal approach to professional education. Journal of Student Wellbeing 3(1), 52–72. Yager, Z. & O’Dea, J. (2005) The role of teachers and other educators in the prevention of eating disorders and child obesity: What are the issues? Eating Disorders: The Journal of Treatment and Prevention 13, 261–278. Yager, Z. & O’Dea, J. (2009). Body image, dieting and disordered eating and activity practices among teacher trainees: implications for school-based health education and obesity prevention programs. Health Education Research 24(3), 472–482.

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Childhood overweight and obesity in developed countries: Global trends and correlates

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Childhood overweight and obesity in developed countries: Global trends and correlates Tim Olds Carol Maher

DOI:10.1093/acprof:oso/9780199572915.003.0006

Abstract and Keywords The belief that the prevalence of overweight and obesity among children globally has been, and continues to be, increasing exponentially has become a media commonplace: research indicates that if childhood obesity rates continue to soar, half of all Australian children will be overweight by the year 2025. This view has been echoed by a number of public health advocates. The British Heart Foundation, for example, recently claimed that more than two thirds of British children will be overweight by 2050 and that Britain as a whole is heading for an obesity epidemic. Several studies have used exponential models to describe secular trends in the prevalence of childhood overweight in Australia, in Europe, and globally. In 2006, Norton and colleagues, for example, reported that overweight prevalence among Australian children has accelerated since the early 1970s, and predicted that it will continue to climb, reaching adult rates by 2035. At the same time, there is emerging evidence of a flattening in rates of increase, and concern that childhood obesity has become a ‘moral panic’ which may have deleterious consequences in terms of increasing stress, anxiety, body image dissatisfaction, and eating disorders. Given these conflicting views, this chapter collates and synthesizes available data on global historical (40–50 year) trends in children's fatness, using body mass index (BMI) and skinfold thicknesses as metrics; comments on recent (5–10 year) trends; and describes the correlates of overweight and obesity.

Keywords: children, adolescents, epidemiology, correlates, global, BMI

Chapter summary The belief that the prevalence of overweight and obesity among children globally has been, and continues to be, increasing exponentially has become a media commonplace:

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Childhood overweight and obesity in developed countries: Global trends and correlates

Research indicates that if childhood obesity rates continue to soar, half of all Australian children will be overweight by the year 2025. Working mums – fat kids. Clare Masters. January 11, 2007, Daily Telegraph, Sydney. http://www.news.com.au/story/0,23599,21041424-36398,00.html. This view has been echoed by a number of public health advocates. The British Heart Foundation, for example, recently claimed that more than two thirds of British children will be overweight by 2050 and that Britain as a whole is heading for an obesity epidemic … Fat Kids: British Parents Wake Up Call, Jack Millar, September 28, 2009, WCJB World News, UK. http://www.wcjb.co.uk/fat-kids-british-parents-wake-up-call-23460. The scientific literature concurs: Given the current prevalence of childhood obesity and its geographic distribution throughout the United States, the term ‘pandemic’ is appropriate for describing the current status of childhood obesity. (Kimm & Obarzanek, 2002) Several studies have used exponential models to describe secular trends in the prevalence of childhood overweight in Australia (Booth et al., 2003), in Europe (Jackson-Leach & Lobstein, 2006), and globally (Lobstein et al., 2004). In 2006, Norton and colleagues (Norton et al., 2006), for example, reported that overweight prevalence among Australian children has accelerated since the early 1970s, and predicted that it will continue to climb, reaching adult rates by 2035. At the same time, there is emerging evidence of a flattening in rates of increase (Section 4), and concern that childhood obesity has become a ‘moral panic’, which may have deleterious consequences in terms of increasing stress, anxiety, body image dissatisfaction, and eating disorders (Gard & Wright, 2005). Given these conflicting views, the aims of this chapter are to 1 collate and synthesize available data on global historical (40–50-year) trends in children’s fatness, using body mass index (BMI) and skinfold thicknesses as metrics; 2 comment on recent (5–10-year) trends; and 3 describe the correlates of overweight and obesity.

(p.70) Introduction Historical trends in body mass index It is exceedingly difficult to collate good-quality national-level data on paediatric overweight and obesity. There have been very few random national samples, and fewer still serial surveys using high-quality sampling procedures. Prevalence rates and trends will vary with age and sex, from region to region within the same country, across different socio-demographic slices (O'Dea & Caputi, 2001), ethnicities (de Wilde et al., 2009), and with methodologies (for example,

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Childhood overweight and obesity in developed countries: Global trends and correlates

measured heights and weights tend to yield higher prevalence estimates than self-reported values (Jansen et al., 2006)). Some surveys are not published in the scholarly literature, but only as government reports, whereas others are not available to the public. Prevalence rates are also very labile over short time periods. Nevertheless, we have gathered data on more than 1.6 million children from 45 countries, where the prevalence of overweight and obesity was quantified using the International Obesity Task Force cut-offs, based on BMI (Cole et al., 2000). Trend data were available from 23 developed countries, covering more than 1.4 million children aged between 2 and 18, organized into 886 age × sex × country × year slices (Aarup et al., 2008; Apfelbacher et al., 2008; Celi et al., 2003; de Wilde et al., 2009; Heude et al., 2003; Janssen et al., 2005; Kalies et al., 2002; Kirchengast & Schober, 2006; Klein-Platat et al., 2003; Lager et al., 2009; Lasserre et al., 2007; Lobstein & Frelut, 2003; Matsushita et al., 2004; Olds et al., 2009; Petersen et al., 2000; Popkin et al., 2006; Rami et al., 2004; Schnohr et al., 2005; Schober et al., 2007; So et al., 2008; Stamatakis et al., 2005; Subramanyam et al., 2003; Tutkuviene, 2007; Valerio et al., 2006; van den Hurk et al., 2007; Vignerová et al., 2007; Will et al., 2005; Woringer & Schütz, 2003; Yngve et al., 2008; Zimmermann et al., 2004). Collectively, these data covered the period from 1970 to 2008, with the span of years for individual countries ranging from 5 to 32 years. The number of reports for each country varied from 3 to 424. Although this is not intended to be a comprehensive review of available information – a task far beyond the scope of this chapter – the data do provide some insight into global trends. In each case, prevalence estimates were regressed against year of measurement using a linear model. The slope of the line represented the average annual rate of change. There have been increases in 16 of these 23 countries, ranging from +1.04% per annum (Chile) to +0.05% per annum (Czech Republic). These results are shown in Fig. 6.1. All the six Pacific Rim countries (Australia, Canada, Chile, Hong Kong, Japan, and the USA) showed increases in prevalence estimates. Results were more mixed among the European countries, but trends were generally upwards. When rates of change were plotted against the span of measurement years in a funnel plot (Fig. 6.2), they gravitated towards a mean increase of about 0.5% per annum. This value was typical of the countries for which the most data were available: Australia (424 reports, +0.38%), Canada (12 reports, +0.66%), Germany (12 reports, +0.33%), Japan (32 reports, +0.32%), Sweden (21 reports, +0.61%), UK (56 reports, +0.55%), and the USA (37 reports, +0.70%). Data from the countries in which there were declines tended to cover a smaller span of years, with only Lithuania (69 reports, −0.11%) having data spanning more than 10 years. Overall, these data suggest that over a period of three decades or so, the prevalence of childhood overweight and obesity has been increasing in most developed countries at the rate of about 5% per decade. Historical trends in skinfold thicknesses The limitations of BMI as a method of quantifying fatness, and of arbitrary categorizations of children as overweight or obese, are well known. Skinfolds offer a more direct measure of fatness. (p.71)

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Childhood overweight and obesity in developed countries: Global trends and correlates

(p.72) As with BMI, collating data on trends in skinfold thicknesses is no easy task. In a previous study (Olds, 2009), we attempted to synthesize all available data on skinfold measurements in children from developed countries, and to chart secular trends. We focused on triceps and subscapular sites, because of consistency in site definition, which is a major source of error in skinfold

Fig. 6.1 Linear trends in the prevalence of overweight and obesity in children in 23 countries.

measurement (Ruiz et al., 1971), because they are easy to locate and measure; have been used in a number of very large surveys; and provide inputs into the Slaughter equations (Slaughter et al., 1988), which were used to estimate percentage body fat. A total of 154 studies with usable data were located, which included data on more than 458,547 young people (some studies did not report sample sizes). Of these, raw data were available from 12 studies (n = 55,849), and the rest provided summary data only (means, standard deviations and/or percentiles). Most of the data came from the USA (122,540 young people), the UK (94,762), Australia (37,494), and Canada (15,359). The full list of studies is available in Olds (2009). Over this five-decade period, age- and sexadjusted skinfold thicknesses increased at the rate of 0.49 (95% confidence limits 0.43–0.56) mm per decade (triceps) and 0.38 (0.33–0.42) mm per decade (subscapular). Rates of change were similar for boys and girls, but were greatest in the

Fig. 6.2 Funnel plot of the rate of change in the prevalence of overweight and obesity in 23 developed countries (vertical axis) against the span of years over which measurements were taken (horizontal axis). Reproduced from Olds, T.S. (2009) with permission from Macmillan Publishers Ltd.

peripubertal age group (10–14 years). Fig. 6.3 shows the trends in triceps skinfold thickness. The rate of increase becomes markedly steeper after about 1980. Age- and sex-adjusted estimated percentage body fat increased over the 50-year period at an average rate of 0.86 (0.76–0.96)% body fat per decade. Rates of increase were greater for boys (1.0% body fat per decade) than for girls (0.7% body fat per decade). Rates of change were greatest in the peripubertal age group (10–14 years). (p.73)

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Childhood overweight and obesity in developed countries: Global trends and correlates

There was also evidence of trends in the distribution of body fat. The ratio of triceps skinfold thickness to subscapular skinfold thickness (T: S ratio) is often taken as a measure of peripheral versus central fat accumulation. The age- and sex-adjusted T: S ratio decreased significantly from 1.50 in 1952 to 1.38 in 2002. This reflects trends found in several countries towards greater central fat accumulation (Dollman & Olds, 2006). Finally, there was evidence that the distribution of fatness across the population has been changing, with increasing positive skews (that is, a larger number of fatter children, and higher levels of fatness). This was evidenced by increasing coefficients of variation in the distributions of skinfold thicknesses, and increasing mean–median Fig. 6.3 Trends in age- and sex-adjusted differences. triceps thickness in children from 31 countries. The line shown is a Lowess curve Taken as a whole, the skinfold data confirm (tension = 66). the long-term trends in BMI: children in developed countries have been getting fatter, with a nonlinear increase after about 1985. In 1951, the average boy had 11.0% body fat and the average girl 17.4%. By 2003, this had increased to 16.2% for boys and 22.2% for girls. Using the skinfold dataset, the average (age- and sex-adjusted) increase in body mass was 1.4 kg per decade. Of this, increases in fat mass represented 0.8 kg, and increases in fat-free mass 0.6 kg. The relative rate of increase in body fat was about 7% per decade. In other words, our children are likely to be about 20% fatter than we were, when we were their age. Recent trends – the end of the epidemic? Some recent reports have brought into question the continuing upward trend in the prevalence of overweight and obesity, suggesting that we are seeing a plateau. BMI data from Australia (O' Dea, 2008a; Olds et al., 2009), China (Shi Zumin, personal correspondence, 25 April, 2009), France (Lioret et al., 2009; Péneau et al., 2009; Romon et al., 2009; Salanave et al., 2008), Greenland (Schnohr et al., 2005), Italy (Lazzeri et al., 2008), the Netherlands (de Wilde et al., 2009), New Zealand (New Zealand Ministry of Health, 2008), Russia (Popkin et al., 2006), Sweden (Lager et al., 2009; Lissner et al., 2009; Sjöberg et al., 2008; Sundblom et al., 2008), Switzerland (Aeberli et al., 2009), the UK (Mitchell et al., 2007; National Health Service Information Centre for Health and Social Care, 2008), and the USA (The Centers for Disease Control and Prevention’s (CDC) (p.74)

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Childhood overweight and obesity in developed countries: Global trends and correlates

(p.75) Pediatric Nutrition Surveillance System (PedNSS) (Sharma et al., 2009); National Survey of Children’s Health (NSCH) (Child and Adolescent Health Measurement Initiative); National Health and Nutrition Examination Survey (NHANES) (Ogden et al., 2008); and the CDC’s Youth Risk Behavior Survey (YRBS) (Centers for Disease Control and Prevention, 2008; Eaton et al., 2008)) have noted stabilization in the rates of childhood overweight and obesity in the last 5 to 10 years (Table 6.1; Fig. 6.4). These data represent 58 reports derived from 21 studies in 11 countries. Of these 58 reports, 35 showed declines or no change in prevalence, and 47 showed increases of less than 0.25% per annum, or half the average rate of increase over the last few decades (Section 2). The mean (SD) rate of change was −0.15 (0.78)% per annum. These studies offer a consistent picture of flattening prevalence in some European and developed Pacific Rim countries. Although they cover a relatively short time frame, they cast doubt upon the widespread belief that the prevalence of obesity is continuing to increase, and a fortiori at an increasing rate.

Fig. 6.4 Changes in the prevalence of overweight and/or obesity in 11 countries in the last 10 years. The name of the study is shown next to each data line. Separate symbols are used for males and females. Simple filled circles represent data on both males and females. HSE = Health Survey of England; NZ MoH = New Zealand Ministry of Health; NSCH = National Survey of Children’s Health; OWOB = overweight or obese; OB = obese; YRBS = Youth Risk Behavior Survey.

In addition to the studies reported here, Olds et al. (2009) reviewed all available surveys of the weight status of Australian children since 1985. The estimated prevalence of obesity in boys rose from 1.0% in 1985 to 5.4% in 1996, but stabilized to remain at 5.3% in 2008. In girls, the estimated prevalence rose rapidly from 0.8% in 1985 to 5.7% in 1996, but increased to only 5.9% by 2008. The estimated prevalence of overweight and obesity in boys rose from 10.2% in 1985 to 21.6% in 1996, flattening to 23.7% in 2008. In girls, the estimated prevalence rose from 11.6% in 1985 to 24.3% in 1996, but then rose to just 24.8% by 2008. Between 1996 and 2008, average BMI zscores rose at less than one-sixth of the 1985–1996 rate of increase.

Discussion Available data suggest that over the last three decades, the prevalence of overweight and obesity among children in wealthy countries has been increasing at the rate of about 0.5% per

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Childhood overweight and obesity in developed countries: Global trends and correlates

annum, and that children and adolescents have been getting fatter whatever metric of fatness is used. What might be the causes of these trends? Overweight arises from an imbalance of energy intake and energy expenditure. Although there have been increases in energy in the available food supply, the self- and proxy-reported intakes of children have generally shown decreases rather than increases (Stevenson, 2007). It is extremely difficult to consistently chart trends in energy expenditure, although some studies have suggested secular decreases in moderate to vigorous physical activity (Dollman & Olds, 2006). A host of factors modulating energy intake and expenditure have also been implicated, including decreases in sleep (Dollman et al., 2007), increases in the consumption of specific foods, such as sweetened beverages and take away food (Ebbeling et al., 2002), excessive screen time (Berkey et al., 2000), and changes in the built environment making active transport less viable (Harten & Olds, 2004). More surprising is the apparent flattening over the last decade. We may indeed be seeing a global turning point. Flattening trends may be associated with a greater consciousness of the issues around childhood obesity. In the last 5–10 years there has been massive media attention and health research directed towards childhood overweight. There have been initiatives at the home, school, community, and local, state, and federal government levels, and some recent reports have shown improvements in diet (Lissner et al., 2009) and in the physical activity and fitness of children (Hardy et al., 2008). Alternatively, we may be reaching a global ‘saturation point’. It may be that the environment in developed countries is so obesogenic, that there is such easy access to high-energy density foods, that we are so saturated with seductive opportunities for sedentary behaviours that any child with the least predisposition to becoming overweight has become overweight, and the rest will be resilient no matter what the environment. In other words, (p.76)

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Childhood overweight and obesity in developed countries: Global trends and correlates

Table 6.1 Reports of recent stabilization of the prevalence of overweight and obesity. The table shows the country of the study, the reference, the sex and age group of the children and adolescents, the weight status examined, the metric used to quantify overweight and/or obesity, and prevalence rates in. The last column shows the rate of change in prevalence (% per year) in each report Country

Ref

Sex

Australia

O'Dea

China France

Weight status

Metric

Both 6 to 16

OB

IOTF

Shi

Both 12 to 14

OWOB

IOTF

Lioret

Both 3 to 14

OWOB

IOTF

Péneau

M

6 to 15

OWOB

IOTF

14.1 13.3 14.2 13.9 15.9 12.2 15.8 12.5 15.3

0.07

F

7 to 15

OWOB

IOTF

15.6 16.3 15.4 15.9 14.1 15.0 15.0 15.6 15.2

−0.09

M

5 to 12

OWOB

IOTF

9.5

F

5 to 12

OWOB

IOTF

17.1 13.6 10.4

Both 7 to 9

OB

IOTF

3.8

4.8

0.14

Both 7 to 9

OWOB

IOTF

18.1

19.7

0.23

National Health Service

Both 5 to 12

OB

IOTF

4.1

3.5

−0.34

Both 5 to 12

OWOB

IOTF

18.9

17.0

−0.95

Schnohr

Both 6 to 7

OB

IOTF

3.6

5.2

0.32

Both 7 to 7

OWOB

IOTF

21.1

21.7

0.12

Both 9

OWOB

IOTF

Both 11

OWOB

IOTF

Both 13

OWOB

Both 15

OWOB

Romon

Salanave

Greenland

Italy

Lazzeri

Age

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Slope 5.0

5.8 15.2

15.2

7.7

0.13 15.0

−0.04

14.5

−0.09

7.4

−1.05 −3.35

31.7

33.4

0.43

20.7

19.6

−0.55

IOTF

16.8

17.9

0.55

IOTF

13.3

19.7

3.35

Page 8 of 18

Childhood overweight and obesity in developed countries: Global trends and correlates

Country

Ref

Netherlands de Wilde

New Zealand

NZ MoH

Switzerland Aeberli

Sex

Age

Weight status

Metric

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Slope

M

3 to 6

OB

IOTF

1.8

1.2

−0.08

M

7 to 10

OB

IOTF

3.3

4.8

0.19

M

13 to 16

OB

IOTF

0.9

2.5

0.20

F

3 to 6

OB

IOTF

3.4

3.5

0.01

F

7 to 10

OB

IOTF

4.5

3.6

−0.11

F

13 to 16

OB

IOTF

3.1

2.3

−0.10

M

3 to 6

OWOB

IOTF

9.4

6.4

−0.38

M

7 to 10

OWOB

IOTF

14.1

19.7

0.70

M

13 to 16

OWOB

IOTF

12.4

14.7

0.29

F

3 to 6

OWOB

IOTF

14.2

11.9

−0.29

F

7 to 10

OWOB

IOTF

20.7

17.7

−0.38

F

13 to 16

OWOB

IOTF

16.3

15.0

−0.16

M

5 to 14

OB

IOTF

8.1

8.1

0.00

F

6 to 14

OB

IOTF

10.0

8.7

−0.26

M

7 to 14

OWOB

IOTF

26.1

28.1

0.40

F

8 to 14

OWOB

IOTF

31.7

28.8

−0.58

M

6 to 13

OB

CDC 2000 95%ile

7.4

5.3

−0.42

Page 9 of 18

Childhood overweight and obesity in developed countries: Global trends and correlates

Country

Sweden

Ref

Lager

Sjöberg

Sundblom

United Kingdom

National Health Service

Sex

Age

Weight status

Metric

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Slope

F

6 to 13

OB

CDC 2000 95%ile

5.7

3.3

−0.48

M

6 to 13

OWOB

CDC 2000 85%ile

19.9

18.9

−0.20

F

6 to 13

OWOB

CDC 2000 85%ile

16.8

13.3

−0.70

Both 7 to 15

OB

IOTF

5.2

Both 7 to 15

OWOB

IOTF

23.3 21.5 21.9

−0.70

M

10

OB

IOTF

2.9

2.8

−0.03

M

10

OWOB

IOTF

17.1

17.6

0.13

F

10

OB

IOTF

3.0

2.5

−0.13

F

10

OWOB

IOTF

19.6

15.9

−0.93

F

10

OB

IOTF

4.4

2.8

−0.40

F

10

OWOB

IOTF

22.1

19.2

−0.73

M

10

OB

IOTF

3.2

3.8

0.15

M

10

OWOB

IOTF

22.6

20.5

−0.53

Both 2 to 15

OB

UK90 95%ile

13.4 15.1 14.3 15.0 17.0 16.6 18.8 18.3 16.0 16.5

0.40

Both 2 to 15

OWOB

UK90 85%ile

27.5 29.0 26.8 30.1 30.8 31.2 34.0 32.6 29.7 30.4

0.44

Page 10 of 18

4.4

3.6

−0.80

Childhood overweight and obesity in developed countries: Global trends and correlates

Country

USA

Ref

Sex

Mitchell

Both primary OB

UK90 95%ile

Sharma (PedNSS)

Both 2 to 4

OW

CDC 2000 95%ile

NSCH

Both 10 to 17

OB

CDC 2000 95%ile

14.8

16.4

0.40

Both 10 to 17

OW

CDC 2000 85– 〈95%ile

15.7

15.3

−0.10

Both 2 to 19

OB

CDC 2000 97%ile

11.7

10.9

−0.40

Both 2 to 19

OB

CDC 2000 95%ile

17.1

15.5

−0.80

Both 2 to 19

OWOB

CDC 2000 85%ile

33.7

30.1

−1.80

Both 14 to 17

OB

CDC 2000 95%ile

10.7

Both 14 to 17

OW

CDC 2000 85– 〈95%ile

14.4

Ogden (NHANES)

YRBS

Age

Weight status

Metric

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Slope 11.4 12.4

10.2

−0.40

14.5

Page 11 of 18

10.5

12.1

14.6 0.22

13.1

13.0

0.36

15.8

0.18

Childhood overweight and obesity in developed countries: Global trends and correlates

CDC = Centers for Disease Control and Prevention; F = female; IOTF = International Obesity Task Force; M = male; NHANES = National Health and Nutrition Examination Survey; NSCH = National Survey of Children’s Health; NZ MoH = New Zealand Ministry of Health; OB = obese; OWOB = overweight or obese; PedNSS = Pediatric Nutrition Surveillance System (Sharma et al., 2009); UK90 = UK 1990 reference standards; YRBS = Youth Risk Behaviour Survey.

Page 12 of 18

Childhood overweight and obesity in developed countries: Global trends and correlates

(p.77) (p.78) (p.79) (p.80) we have reached a point of equilibrium, which may be temporary. Finally, a self-selection effect cannot be ruled out. It is possible that fatter children, and their parents, are less likely to volunteer to be measured today than they were 5 or 10 years ago, due to increased stigmatization of obesity and overweight. It must be emphasised that despite promising overall trends, prevalence rates remain high across the developed world, and socio-economic gradients strong. The slowing of the trend does not appear to be uniform across all socio-demographic groups. It appears to be stronger in urban than in rural areas, and stronger amongst boys than amongst girls (Lissner et al., 2009). Some studies have found flattening trends in high-SES but not low-SES groups (O'Dea, 2008b), and differential trends across different ethnic groups (de Wilde et al., 2009). References Bibliography references: Aarup, M., Sokolowski, I., & Lous, J. (2008) The prevalence of obesity and overweight among 3 year-old children in the municipality of Aalborg and identification of risk factors. Ugeskr Laeger 170(6), 452–456. Aeberli, I., Ammann, R., Knabenhans, M., Molinari, L., & Zimmermann, M. (2009) Decrease in the prevalence of paediatric adiposity in Switzerland from 2002 to 2007. Public Health Nutrition Sep 22, 1–6. [Epub ahead of print]. Apfelbacher, C., Cairns, J., Bruckner, T., et al. (2008) Prevalence of overweight and obesity in East and West German children in the decade after reunification: population-based series of cross-sectional studies. Journal of Epidemiology and Community Health 62(2), 125–130. Berkey, C.S., Rockett, H.R., Field, A.E., et al. (2000) Activity, dietary intake, and weight changes in a longitudinal study of preadolescent and adolescent boys and girls. Pediatrics 105(4), E56. Booth, M.L., Chey, T., Wake, M., et al. (2003) Change in the prevalence of overweight and obesity among young Australians, 1969–1997. American Journal of Clinical Nutrition 77, 29–36. Celi, F., Bini, V., De Giorgi, G., et al. (2003) Epidemiology of overweight and obesity among school children and adolescents in three provinces of central Italy, 1993–2001: study of potential influencing variables. European Journal of Clinical Nutrition 57(9), 1045–1051. Centers for Disease Control and Prevention (2008) Trends in the Prevalence of Obesity, Dietary Behaviors, and Weight Control Practices National YRBS: 1991–2007, viewed 30 November 2009, 〈〉. Child and Adolescent Health Measurement Initiative (2007) National Survey of Children's Health, viewed 1 December 2009, 〈〉. Cole, T.J., Bellizzi, M.C., Flegal, K.M., & Dietz, W.H. (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ (Clinical Research Ed.) 320(7244), 1240–1243.

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Childhood overweight and obesity in developed countries: Global trends and correlates

de Wilde, J., van Dommelen, P., Middelkoop, B., & Verkerk, P. (2009) Trends in overweight and obesity prevalence in Dutch, Turkish, Moroccan and Surinamese South Asian children in the Netherlands. Archives of Disease in Childhood 94(10), 795–800. Dollman, J. & Olds, T. (2006) Secular changes in fatness and fat distribution in Australian children matched for body size. International Journal of Pediatric Obesity 1(2), 109–113. Dollman, J., Ridley, K., Olds, T., & Lowe, E. (2007) Trends in the duration of school-day sleep among 10- to 15-year-old South Australians between 1985 and 2004. Acta Paediatrica 96(7), 1011–1014. Eaton, D.K., Kann, L., Kinchen, S., et al. (2008) Youth risk behavior surveillance – United States, 2007. Morbidity and Mortality Weekly Report Surveillance Summaries 57(SS04), 1–131. Ebbeling, C.B., Pawlak, D.B., & Ludwig, D.S. (2002) Childhood obesity: public-health crisis, common sense cure. Lancet 360(9331), 473–482. Gard, M. & Wright, J. (2005) The obesity epidemic: science, morality and ideology, Routledge, London. Hardy, L., Okely, A., Dobbins, T., & Booth, M. (2008) Physical activity among adolescents in New South Wales (Australia): 1997 and 2004. Medicine and Science in Sports and Exercise 40(5), 835–841. Harten, N. & Olds, T. (2004) Patterns of active transport in 11–12 year old Australian children. Australian and New Zealand Journal of Public Health 28(2), 167–172. Heude, B., Lafay, L., Borys, J., et al. (2003) Time trend in height, weight, and obesity prevalence in school children from Northern France, 1992–2000. Diabetes and Metabolism 29(3), 235–240. Jackson-Leach, R. & Lobstein, T. (2006) Estimated burden of paediatric obesity and comorbidities in Europe: Part 1: The increase in prevalence of childhood obesity in Europe is itself increasing. International Journal of Pediatric Obesity 1, 26–32. Jansen, W., van de Looij-Jansen, P., Ferreira, I., de Wilde, E., & Brug, J. (2006) Differences in measured and self-reported height and weight in Dutch adolescents. Annals of Nutrition and Metabolism 50(4), 339–346. Janssen, I., Katzmarzyk, P., Boyce, W., et al. (2005) Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationships with physical activity and dietary patterns. Obesity Reviews 6(2), 123–132. Kalies, H., Lenz, J., & von Kries, R. (2002) Prevalence of overweight and obesity and trends in body mass index in German pre-school children, 1982–1997. International Journal of Obesity 26(9), 1211–1217. Kimm, S. & Obarzanek, E. (2002) Childhood obesity: a new pandemic of the new millennium. Pediatrics 110(5), 1003–1007.

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Kirchengast, S. & Schober, E. (2006) Obesity among female adolescents in Vienna, Austria – the impact of childhood weight status and ethnicity. British Journal of Obstetrics and Gynaecology 113(10), 1188–1194. Klein-Platat, C., Wagner, A., Haan, M., Arveiler, D., Schlienger, J., & Simon, C. (2003) Prevalence and sociodemographic determinants of overweight in young French adolescents. Diabetes/Metabolism Research and Reviews 19(2), 153–158. Lager, A., Fossum, B., Rörvall, G., & Bremberg, S. (2009) Children's overweight and obesity: local and national monitoring using electronic health records. Scandinavian Journal of Public Health 37(2), 201–205. Lasserre, A., Chiolero, A., Cachat, F., Paccaud, F., & Bovet, P. (2007) Overweight in Swiss children and associations with children’s and parents’ characteristics. Obesity (Silver Spring) 15(12), 2912–2919. Lazzeri, G., Rossi, S., Pammolli, A., Pilato, V., Pozzi, T., & Giacchi, M. (2008) Underweight and overweight among children and adolescents in Tuscany (Italy). Prevalence and short-term trends. Journal of Preventive Medicine and Hygiene 49(1), 13–21. Lioret, S., Touvier, M., Dubuisson, C., et al. (2009) Trends in child overweight rates and energy intake in France from 1999 to 2007: relationships with socioeconomic status. Obesity (Silver Spring) 15(5), 1092–1100. Lissner, L., Sohlström, A., Sundblom, E., & Sjöberg, A. (2009) Trends in overweight and obesity in Swedish schoolchildren 1999–2005: has the epidemic reached a plateau? Obesity Reviews. Lobstein, T. & Frelut, M. (2003) Prevalence of overweight among children in Europe. Obesity Reviews 4(4), 195–200. Lobstein, T., Baur, L., & Uauy, R. (2004) Obesity in children and young people: a crisis in public health. Obesity Reviews 5(Suppl 1), 4–85. Matsushita, Y., Yoshiike, N., Kaneda, F., Yoshita, K., & Takimoto, H. (2004) Trends in childhood obesity in Japan over the last 25 years from the national nutrition survey. Obesity Research 12(2), 205–214. Mitchell, R., McDougall, C., & Crum, J. (2007) Decreasing prevalence of obesity in primary schoolchildren. Archives of Disease in Childhood 92(2), 153–154. National Health Service Information Centre for Health and Social Care (2008) National Child Measurement Programme 2007/08 School Year Headline Results, IC, Leeds. New Zealand Ministry of Health (2008) A portrait of health: key results of the 2006/07 New Zealand Health Survey, New Zealand Ministry of Health, Wellington.

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Norton, K., Dollman, J., Martin, M., & Harten, N. (2006) Descriptive epidemiology of childhood overweight and obesity in Australia: 1901–2003. International Journal of Pediatric Obesity 1, 232–238. O' Dea, J. (2008a) Inquiry into obesity in Australia, Report commissioned by the Standing Committee on Health and Ageing: Australian Government House of Representatives. O'Dea, J. (2008b) Gender, ethnicity, culture and social class influences on childhood obesity among Australian schoolchildren: implications for treatment, prevention and community education. Health and Social Care in the Community 16(3), 282–290. O'Dea, J. & Caputi, P. (2001) Association between socioeconomic status, weight, age and gender, and the body image and weight control practices of 6- to 19-year-old children and adolescents. Health Education Research 16(5), 521–532. Ogden, C.L., Carroll, M.D., & Flegal, K.M. (2008) High body mass index for age among US children and adolescents. JAMA: the Journal of the American Medical Association 299(20), 2401– 2405. Olds, T.S. (2009) One million skinfolds: secular trends in the fatness of young people 1951–2004. European Journal of Clinical Nutrition 63, 934–946. Olds, T.S., Tomkinson, G.R., Ferrar, K.E., & Maher, C.A. (2009) Trends in the prevalence of childhood overweight and obesity in Australia between 1985 and 2008. International Journal of Obesity. vol. advance online publication 13 October 2009; doi: 10.1038/ijo.2009.211 Péneau, S., Salanave, B., Maillard-Teyssier, L., et al. (2009) Prevalence of overweight in 6- to 15year-old children in central/western France from 1996 to 2006: trends toward stabilization. International Journal of Obesity 33(4), 401–407. Petersen, T., Nielsen, A., Paludan, M., Rasmussen, S., & Madsen, M. (2000) Børns Sundhed ved Slutningen af Skolealderen: En Undersøgelse Blandt Eleverne i 8 og 9 Klasse i 1996/97 [Children's health at the end of schoolage: a survey among pupils in grade 8 and 9 in 1996/97], National Institute of Public Health, Copenhagen. Popkin, B., Conde, W., Hou, N., & Monteiro, C. (2006) Is there a lag globally in overweight trends for children compared with adults? Obesity (Silver Spring) 14(10), 1846–1853. Rami, B., Schober, E., Kirchengast, S., Waldhör, T., & Sefranek, R. (2004) Prevalence of overweight and obesity in male adolescents in Austria between 1985 and C000. A population based study. Journal of Pediatric Endocrinology and Metabolism 17(1), 67–72. Romon, M., Lommez, A., Tafflet, M., et al. (2009) Downward trends in the prevalence of childhood overweight in the setting of 12-year school- and community-based programmes. Public Health Nutrition. 12(10), 1735–1742.

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Ruiz, L., Colley, J., & Hamilton, P. (1971) Measurement of triceps skinfold thickness: an investigation of sources of variation. British Journal of Preventive and Social Medicine 25(3), 165–167. Salanave, B., Péneau, S., Rolland-Cachera, M., Castetbon, K., & Hercberg, S. (2008) Prevalence of overweight in 7–9 year-old French children in 2000 and 2007 and factors associated with overweight. Obesity Reviews 9, S18. Schnohr, C., Sørensen, T., & Niclasen, B. (2005) Changes since 1980 in body mass index and the prevalence of overweight among inschooling children in Nuuk, Greenland. International Journal of Circumpolar Health 64(2), 157–162. Schober, E., Rami, B., Kirchengast, S., Waldhör, T., & Sefranek, R. (2007) Recent trend in overweight and obesity in male adolescents in Austria: a population-based study. European Journal of Pediatrics 166(7), 709–714. Sharma, A.J., Grummer-Strawn, L.M., Dalenius, K., et al. (2009) Obesity prevalence among lowincome, preschool-aged children – United States, 1998–2008. Morbidity and Mortality Weekly Report 58(28), 769–773. Sjöberg, A., Lissner, L., Albertsson-Wikland, K., & Mårild, S. (2008) Recent anthropometric trends among Swedish school children: evidence for decreasing prevalence of overweight in girls. Acta Paediatrica 97(1), 118–123. Slaughter, M., Lohman, T., Boileau, R., et al. (1988) Skinfold equations for estimation of body fatness in children and youth. Human Biology 60(5), 709–723. So, H., Nelson, E., Li, A., et al. (2008) Secular changes in height, weight and body mass index in Hong Kong Children. BioMed Central Public Health 8, 320. Stamatakis, E., Primatesta, P., Chinn, S., Rona, R., & Falascheti, E. (2005) Overweight and obesity trends from 1974 to 2003 in English children: what is the role of socioeconomic factors? Archives of Disease in Childhood 90(10), 999–1004. Stevenson, J. (2007) Secular trends in the reported energy intakes of young people. Honours thesis, University of South Australia. Subramanyam, V., Jayashree, R., & Rafi, M. (2003) Prevalence of overweight and obesity in affluent adolescent girls in Chennai in 1981 and 1998. Indian Pediatrics 40(4), 332–336. Sundblom, E., Petzold, M., Rasmussen, F., Callmer, E., & Lissner, L. (2008) Childhood overweight and obesity prevalences levelling off in Stockholm but socioeconomic differences persist. International Journal of Obesity 32(10), 1525–1530. Tutkuviene, J. (2007) Body mass index, prevalence of overweight and obesity in Lithuanian children and adolescents, 1985–2002. Collegium Antropologicum 31(9), 109–121.

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Valerio, G., D’Amico, O., Adinolfi, M., Munciguerra, A., D’Amico, R., & Franzese, A. (2006) Determinants of weight gain in children from 7 to 10 years. Nutrition, Metabolism & Cardiovascular Diseases 16(4), 272–278. van den Hurk, K., van Dommelen, P., van Buuren, S., Verkerk, P., & Hirasing, R. (2007) Prevalence of overweight and obesity in the Netherlands in 2003 compared to 1980 and 1997. Archives of Disease in Childhood 92(11), 992–995. Vignerová, J., Humeníkova, L., Brabec, M., Riedlová, J., & Bláha, P. (2007) Long-term changes in body weight, BMI, and adiposity rebound among children and adolescents in the Czech Republic. Economics and Human Biology. 5(3), 409–425. Will, B., Zeeb, H., & Baune, B. (2005) Overweight and obesity at school entry among migrant and German children: a cross-sectional study. BioMed Central Public Health 5, 45. Woringer, V. & Schütz, Y. (2003) Obesity in Switzerland: body mass index (BMI) percentiles of a child and adolescent population born in 1980 in Lausanne and comparison with Swuss norms (1955). Sozial- und Präventivmedizin 48(2), 121–132. Yngve, A., De Bourdeaudhuij, I., Wolf, A., et al. (2008) Differences in prevalence of overweight and stunting in 11-year olds across Europe: The Pro Children Study. European Journal of Public Health 18(2), 126–130. Zimmermann, M., Gübeli, C., Püntener, C., & Molinari, L. (2004) Detection of overweight and obesity in a national sample of 6-12-y-old Swiss children: accuracy and validity of reference values for body mass index from the US Centers for Disease Control and Prevention and the International Obesity Task Force. American Journal of Clinical Nutrition 79(5), 838–843.

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A review of prevalence and trends in childhood obesity in the United States

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

A review of prevalence and trends in childhood obesity in the United States Cynthia L. Ogden Margaret D. Carroll Katherine M. Flegal

DOI:10.1093/acprof:oso/9780199572915.003.0007

Abstract and Keywords In the United States, the prevalence of obesity among 2–19 year old children and adolescents tripled between 1980 and 1999. Between 1999 and 2008, however, the rate of increase slowed and the prevalence did not increase significantly. This chapter presents a review of published results on the obesity prevalence and trends between 1999–2000 and 2007–8 among US children and adolescents. These results are based on the US National Health and Nutrition Examination Survey. Obesity among children and adolescents 2–19 years of age is defined as BMI (weight in kilograms divided by height in meters squared) at or above the 95th percentile on the 2000 CDC sex-specific BMI-for-age growth charts. Although there were no significant linear trends in the prevalence of obesity among children and adolescents between 1999–2000 and 2007–8, the prevalence remains high in the US. Almost 17% of children and adolescents were obese and significant disparities remain by race/ethnicity. These disparities may in part reflect differences in adiposity between race/ethnic groups. Disparities by income and education are not consistent. In the United States, the prevalence of obesity among 2–19 year old children and adolescents tripled between 1980 and 1999. Between 1999 and 2008, however, the rate of increase slowed and the prevalence did not increase significantly. Childhood obesity remains a health concern in part because obese children often become obese adults and can suffer from immediate health consequences such as elevated blood pressure, adverse lipid levels, and insulin resistance. The chapter also presents a review of published results on the obesity prevalence and trends between 1999–2000 and 2007–8 among US children and adolescents. These results are based on the US National Health and Nutrition Examination Survey. Changes in the population distribution of body mass index (BMI) and disparities in obesity prevalence are also presented.

Page 1 of 17

A review of prevalence and trends in childhood obesity in the United States

Keywords: overweight, obesity, children, adolescents, epidemiology, correlates, USA

Chapter summary In the United States, the prevalence of obesity among 2–19-year-old children and adolescents tripled between 1980 and 1999. Between 1999 and 2008, however, the rate of increase slowed and the prevalence did not increase significantly. In this chapter we present a review of published results on the obesity prevalence and trends between 1999–2000 and 2007–2008 among US children and adolescents. These results are based on the US National Health and Nutrition Examination Survey. Obesity among children and adolescents 2–19 years of age is defined as BMI (weight in kilograms divided by height in meters squared) at or above the 95th percentile on the 2000 CDC sex-specific BMI-for-age growth charts. Although there were no significant linear trends in the prevalence of obesity among children and adolescents between 1999–2000 and 2007–2008, the prevalence remains high in the United States. Almost 17% of children and adolescents were obese and significant disparities remain by race/ethnicity. These disparities may in part reflect differences in adiposity between race/ethnic groups. Disparities by income and education are not consistent.

Introduction In the United States, the prevalence of obesity among 2–19-year-old children and adolescents tripled between 1980 and 1999 (Ogden et al., 2002). Between 1999 and 2008, however, the rate of increase slowed and the prevalence did not increase significantly (Ogden et al., 2010a). Childhood obesity remains a health concern in part because obese children often become obese adults (Serdula et al., 1993) and can suffer from immediate health consequences such as elevated blood pressure, adverse lipid levels (Freedman et al., 2009), and insulin resistance (Nathan & Moran, 2008). In this chapter we present a review of published results on the obesity prevalence and trends between 1999–2000 and 2007–2008 among US children and adolescents. These results are based on the US National Health and Nutrition Examination Survey. Changes in the population distribution of body mass index (BMI) and disparities in obesity prevalence are also presented.

Obesity definition Obesity among children and adolescents 2–19 years of age is defined as BMI (weight in kilograms divided by height in meters squared) at or above the 95th percentile on the 2000 CDC sex-specific BMI-for-age growth charts (Kuczmarski et al., 2002). The CDC 2000 growth charts were developed from five US nationally representative surveys (the National Health Examination Surveys II and III in the 1960s, the National Health and Nutrition Examination Survey (NHANES) I and II in the 1970s, and, for children under 6 years, NHANES III, 1988–94). All weight data from NHANES (p.85) III for children 6 and older were excluded from the charts because a secular increase in body weight occurred in the 1980s. The 2000 CDC charts represent a revision of the 1977 NCHS growth charts (Hamill et al., 1977). Until recently in the United States, children at or above the 95th percentile of BMI-for-age were labeled ‘overweight’ and those between the 85th and 95th percentiles were considered ‘at risk for overweight’ based on recommendations from expert committees in the 1990s (Barlow & Dietz, 1998;Himes & Dietz, 1994). A more recent expert committee recommended that

Page 2 of 17

A review of prevalence and trends in childhood obesity in the United States

children 〉=95th percentile of BMI-for-age be labeled ‘obese’ and those between the 85th and 95th percentile be considered ‘overweight’ (Krebs et al., 2007). Although these definitions are not diagnostic criteria, elevated BMI among children often indicates increased risk for future adverse health outcomes and/or development of disease. In this chapter, we focus on children and adolescents at or above the 95th percentile and use the term ‘obesity’. Children at or above the 95th percentile of BMI-for-age are more likely to have excess body fat compared to those between the 85th and 95th percentiles. Children in this lower BMI percentile range make up a more heterogeneous group.

Data Published estimates of obesity prevalence in the United States were obtained from the NHANES, a complex, multi-stage probability sample of the US civilian, non-institutionalized population conducted by the Centers for Disease Control and Prevention (CDC)/National Center for Health Statistics (NCHS) (CDC/NCHS, 2009). The survey has been continuously in the field since 1999 and at least 2 years of data are needed to provide reliable estimates. NHANES was reviewed and approved by the NCHS Ethics Review Board. Mexican Americans and nonHispanic blacks were oversampled during the survey periods 1999–2000 through 2007–2008. Adolescents were over sampled between 1999 and 2006. Participants 16 years and older reported their own race and ethnicity. A family member reported race and ethnicity for children less than 16 years of age. Race/ethnic groups were categorized as non-Hispanic white, non-Hispanic black, and Mexican American. The total population includes an ‘other’ group of primarily Asians and Native Americans but this group does not have sufficient sample size to be analyzed separately. NHANES consists of a home interview followed by a physical examination in a mobile examination centre. Weight and height were measured using standardized protocols and calibrated equipment during the physical exam. Between 1999 and 2004 NHANES also included full body dual-energy X-ray absorptiometry (DXA) scans that measured total body fat or adiposity. Questionnaire and examination response rates for NHANES 1999–2000, 2001–2002, 2003–2004, 2005–2006, and 2007–2008 are similar (Hedley et al., 2004; Ogden et al., 2002; Ogden et al., 2006; Ogden et al., 2008). For example, in 2007–2008, the overall examination response rate for children and adolescents was approximately 84%. Less than 1% of the examined children were missing weight and/or height data. More children were missing DXA scans. In fact, because there was a systematic bias in who was missing DXA scans in NHANES, NCHS developed five multiple imputation files for the DXA data. All previously published analyses followed NHANES analytic guidelines. Statistical analyses were done using SAS (Version 9.2; SAS Institute Inc, Cary, NC) and SUDAAN (Version 10; Research Triangle Institute, Research Triangle Park, NC) and analyses of obesity or body fat excluded pregnant females. Sample weights were used to account for differential non-response, non-coverage, and to adjust for planned over-sampling of some groups. Standard errors were estimated with SUDAAN using Taylor series linearization, a design-based approach. The five DXA multiple imputation files were used to calculate percentage body fat.

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(p.86) Obesity prevalence and trends The most recent data from 2007–2008 indicate that approximately 17% or 12.5 million US children and adolescents are obese (Ogden et al., 2010a). This includes 10.4% of 2–5-year-olds, 19.6% of 6–11-year-olds and 18.1% of 12–19-year-olds. There are significant differences by age. Pre-school age boys and girls are less likely to be obese compared to adolescents (Ogden et al., 2010a). During the period 1999–2008 there were no significant trends in obesity prevalence among boys or girls or in any race/ethnic group (Ogden et al., 2010a). Table 7.1 contains obesity prevalence estimates for 1999–2000, 2001–2002, 2003–2004, 2005–2006, and 2007–2008. Estimates are shown for each sex, age, and race/ethnic group (Ogden et al., 2002; Ogden et al., 2010a; Ogden et al., 2006). Fig. 7.1 displays the overall trends by age group and Fig. 7.2 displays the overall trends by race/ ethnic group for children and adolescents 2–19 years of age.

Distribution of body mass index The trends in obesity prevalence do not provide the whole picture of changes in body weight in the US pediatric population. A more complete picture can be seen in the distributions of BMI at various time periods. Previously published figures have shown increasing skewness and a shift in the distribution of BMI between 1976–1980 and 2003–2006 indicating the heaviest individuals got even heavier (Ogden et al., 2010b). Similar figures show little change between 1999 and 2008. Figs. 7.3 and 7.4 contain the distribution of BMI in 1999–2002 and 2005–2008 among adolescent boys and girls.

Disparities Race/ethnicity Although the prevalence of obesity is high in the general pediatric population in the United States, some sub-groups of the population experience a greater prevalence than other groups. In particular, significant differences exist between race/ethnic groups. Mexican American boys are more likely to be obese compared to non-Hispanic white boys (Ogden et al., 2010a). Among girls, non-Hispanic black girls are more likely to be obese compared to non-Hispanic white girls (Ogden et al., 2010a). In 2007–2008, 24.9% of Mexican American boys and 15.7% of nonHispanic white boys were obese. Among girls, 22.7% of non-Hispanic black and 14.9% of nonHispanic white girls were obese (see Table 7.1). NHANES data have also been used to explore the adiposity level of children and adolescents in different BMI categories (Flegal et al., 2010). There are significant differences in body fat between race/ethnic groups at the same BMI level, especially among those between the 85th and 95th percentiles of BMI (‘overweight’). Non-Hispanic black children have a lower body fat percentage than both non-Hispanic whites and Mexican American children and are less likely to have high adiposity (Flegal et al., 2010). Published results from NHANES 1999–2004 are shown in Figs 7.5 and 7.6. The prevalence of high adiposity (〉=75th age and sex specific percentile) was significantly lower among non-Hispanic black boys and girls compared to non-Hispanic white boys and girls (Flegal et al., 2010).

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A review of prevalence and trends in childhood obesity in the United States

Socioeconomic status Socioeconomic status is often related to obesity. The magnitude and the direction of the association are not consistent across levels of economic development, sex and race/ethnicity (Cassidy, 1991; (p.87)

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A review of prevalence and trends in childhood obesity in the United States

Table 7.1 Trends in the prevalence of obesity, children and adolescents 2–19 years by age, sex, and race/ethnicity, United States, 1999–2008 All Race ethnic groups

2–5 years

6–11 years

12–19 years

n

%

SE

n

%

SE

n

%

SE

n

%

SE

1999–2000

4039

13.9

0.9

726

10.3

1.7

1048

15.1

1.4

2265

14.8

0.9

2001–2002

4261

15.4

0.9

795

10.6

1.8

1165

16.3

1.6

2301

16.7

1.1

2003–2004

3961

17.1

1.3

819

14.0

1.6

982

18.8

1.3

2160

17.4

1.7

2005–2006

4207

15.5

1.3

952

11.0

1.2

1114

15.1

2.1

2141

17.8

1.8

2007–2008

3281

16.9

1.3

885

10.4

1.3

1197

19.6

1.2

1199

18.1

1.7

1999–2000

2071

14.0

1.2

374

9.5

2.3

542

15.8

1.8

1155

14.8

1.3

2001–2002

2126

16.4

1.0

383

10.7

2.4

581

17.5

1.9

1162

17.6

1.3

2003–2004

2004

18.2

1.5

402

15.1

1.7

463

19.9

2.0

1139

18.2

1.9

2005–2006

2114

15.9

1.5

473

10.5

1.7

550

16.2

2.5

1091

18.2

2.4

2007–2008

1725

17.8

1.4

489

10.0

1.4

595

21.2

1.6

641

19.3

2.2

1999–2000

1968

13.8

1.1

352

11.2

2.5

506

14.3

2.1

1110

14.8

1.0

2001–2002

2135

14.3

1.3

412

10.5

1.8

584

14.9

2.4

1139

15.7

1.9

2003–2004

1957

16.0

1.4

417

12.8

2.5

519

17.6

1.3

1021

16.4

2.3

2005–2006

2093

15.0

1.5

479

11.5

1.2

564

14.1

2.4

1050

17.3

2.1

2007–2008

1556

15.9

1.5

396

10.7

2.1

602

18.0

2.1

558

16.8

1.9

All All

Boys

Girls

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A review of prevalence and trends in childhood obesity in the United States

All Race ethnic groups

2–5 years

6–11 years

12–19 years

n

%

SE

n

%

SE

n

%

SE

n

%

SE

1999–2000

1662

20.2

1.4

255

10.9

2.2

423

23.4

2.1

984

23.2

1.8

2001–2002

1256

19.5

1.3

214

15.9

3.2

322

20.1

2.8

720

21.1

1.8

2003–2004

1183

19.2

1.8

228

19.2

4.5

300

22.4

2.4

655

16.3

1.2

2005–2006

1400

22.5

1.8

330

14.5

1.9

371

25.0

3.0

699

25.5

2.2

2007–2008

836

20.8

2.1

233

13.7

2.2

321

24.7

2.7

282

22.2

2.9

1999–2000

869

23.5

1.5

131

13.1

2.3

226

26.7

2.9

512

27.2

3.1

2001–2002

606

22.0

1.3

100

15.4

3.6

158

26.0

2.9

348

21.8

2.4

2003–2004

590

22.0

1.6

111

23.2

5.1

140

25.3

2.2

339

18.3

1.7

2005–2006

689

24.3

2.7

158

14.9

2.8

181

29.7

3.5

350

25.6

3.7

2007–2008

429

24.9

2.2

124

19.3

2.1

156

27.1

3.7

149

26.8

3.1

1999–2000

793

16.8

1.9

124

8.7

3.4

197

19.8

2.4

472

19.3

2.7

2001–2002

650

17.0

1.9

114

16.3

5.9

164

13.6

3.2

372

20.3

2.8

2003–2004

593

16.1

2.3

117

15.1

5.0

160

19.2

3.9

316

14.1

2.0

2005–2006

711

20.6

1.5

172

14.1

2.5

190

20.1

3.4

349

25.4

1.8

2007–2008

407

16.5

2.4

109

7.5

2.6

165

22.3

3.0

133

17.4

4.0

Mexican American All

Boys

Girls

Non-Hispanic white

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A review of prevalence and trends in childhood obesity in the United States

All Race ethnic groups

2–5 years

6–11 years

12–19 years

n

%

SE

n

%

SE

n

%

SE

n

%

SE

1999–2000

878

11.0

1.3

193

8.7

2.0

229

11.8

1.8

456

11.4

1.1

2001–2002

1290

13.8

1.5

257

8.7

2.3

346

14.8

2.3

687

15.2

1.8

2003–2004

1092

16.4

1.8

241

11.7

2.4

256

17.7

2.3

595

17.3

2.2

2005–2006

1103

12.9

1.8

257

9.9

2.0

302

12.3

2.9

544

14.6

2.4

2007–2008

1042

15.3

2.0

311

9.1

1.9

355

19.0

2.1

376

15.6

2.7

1999–2000

446

10.9

1.5

93

6.9

2.5

118

12.0

2.0

235

11.8

1.7

2001–2002

646

15.0

1.5

126

9.6

3.0

176

15.5

2.2

344

16.6

2.0

2003–2004

544

17.8

2.2

119

13.0

3.3

120

18.5

3.9

305

19.1

2.7

2005–2006

569

13.4

1.9

141

9.3

2.8

145

12.8

3.7

283

15.5

2.8

2007–2008

568

15.7

2.0

181

6.6

2.0

188

20.5

2.6

199

16.7

2.8

1999–2000

432

11.1

1.8

100

10.5

3.6

111

11.6

2.9

221

11.0

1.8

2001–2002

644

12.7

1.9

131

7.8

2.1

170

14.1

3.5

343

13.7

2.8

2003–2004

548

14.9

1.9

122

10.3

3.3

136

16.9

1.9

290

15.4

2.9

2005–2006

534

12.3

2.1

116

10.5

2.0

157

11.8

3.6

261

13.5

2.7

2007–2008

474

14.9

2.5

130

12.0

3.3

167

17.4

3.2

177

14.5

3.1

All

Boys

Girls

Non-Hispanic black All

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A review of prevalence and trends in childhood obesity in the United States

All

2–5 years

6–11 years

12–19 years

Race ethnic groups

n

%

SE

n

%

SE

n

%

SE

n

%

SE

1999–2000

1131

18.8

1.0

199

8.7

2.4

312

19.6

1.5

620

23.1

2.0

2001–2002

1338

17.5

1.1

240

8.6

1.8

402

19.9

2.3

696

19.3

1.4

2003–2004

1371

20.0

1.1

258

13.0

1.8

342

22.0

2.0

771

21.7

1.4

2005–2006

1325

21.3

1.5

259

16.7

1.9

331

20.5

3.0

735

24.0

1.7

2007–2008

823

20.0

1.2

191

11.4

2.0

313

19.4

2.5

319

24.4

1.2

1999–2000

585

16.4

1.2

106

6.0

2.8

160

17.1

2.5

319

21.1

2.6

2001–2002

687

15.5

1.3

120

9.7

2.2

203

16.9

1.8

364

16.7

2.5

2003–2004

710

16.4

1.5

125

9.7

2.7

159

17.5

3.0

426

18.4

1.6

2005–2006

687

18.4

1.3

129

16.5

4.1

176

19.7

4.4

382

18.4

2.1

2007–2008

427

17.3

2.2

106

11.1

2.4

153

17.7

3.2

168

19.8

2.6

1999–2000

546

21.4

1.4

93

11.7

2.6

152

22.4

2.3

301

25.2

2.7

2001–2002

651

19.7

1.4

120

7.5

2.3

199

23.1

4.2

332

22.0

2.4

2003–2004

661

23.8

1.4

133

16.3

3.7

183

26.5

2.8

345

25.4

2.0

2005–2006

638

24.4

2.2

130

17.0

2.6

155

21.5

3.0

353

29.8

3.0

2007–2008

396

22.7

2.4

85

11.7

4.1

160

21.1

4.5

151

29.2

2.7

Boys

Girls

SE: standard error; Obesity defined as BMI〉=sex and age specific 95th percentile from the 2000 CDC growth charts. Source: National Health and Nutrition Examination Surveys, 1999-2008, NCHS, CDC.

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A review of prevalence and trends in childhood obesity in the United States

(p.88) (p.89) Sobal & Skunkard, 1989; Chang & Lauderdale, 2005). Higher weight can be associated with wealth and prosperity in some less-developed countries. In many contexts increased muscularity and increased fatness have symbolized power, dominance, wealth, or high social standing. In developed countries, height is positively associated with socioeconomic status but weight and BMI tend to be weakly, if at all, associated with socioeconomic status among men. On the other (p.90)

Fig. 7.1 Trends in obesity* among US children and adolescents by age, 2–19 years. *

Obesity defined as body mass index ( B M I ) = sex and age specific 95th percentile from the 2000 CDC growth charts. Source: National Health and Nutrition Examination Surveys 1999–2008, NCHS, CDC.

Fig. 7.2 Trends in obesity* among US children and adolescents by race/ethnicity, 2–19 years.*Obesity defined as body mass index (BMI) 〉= sex and age specific 95th percentile from the 2000 CDC growth charts. Source: National Health and Nutrition Examination Surveys 1999–2008, NCHS, CDC.

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A review of prevalence and trends in childhood obesity in the United States

hand, BMI has a strong inverse association with socioeconomic status among women, and in particular white women, in developed countries. In the past, slender body might have reflected limited access to food or the need for hard physical labor, whereas today achieving a slender body may require time, money, and effort (Sargent & Blanchflower, 1994; Gortmaker, Must, Perrin, Sobol, & Dietz, 1993). The relationship between socioeconomic status and weight in children is less well studied and less consistent than among adults. Published reports based on NHANES 2003– 2006 show inconsistent relationships between obesity and poverty income ratio

Fig. 7.3 BMI distribution, boys 12–19 years, 1999–2002 and 2005–2008. Source: CDC/NCHS National Health and Nutrition Examination Surveys 1999–2002, 2005–2008.

(PIR) among children (Ogden et al., 2010b). PIR is the ratio of household income to the US federal poverty threshold, accounting for family size and inflation. Analyses by PIR quintile showed that the prevalence of obesity was significantly higher among all (p.91)

Fig. 7.4 BMI distribution, girls 12–19 years, 1999–2002 and 2005–2008. Source: CDC/NCHS National Health and Nutrition Examination Surveys 1999–2002, 2005–2008.

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A review of prevalence and trends in childhood obesity in the United States

Fig. 7.5 Prevalence of high adipositya by BMI category and race/ethnicity among boys 8–19 years, 1999–2004.a High adiposity defined as 〉=internal age and sex specific 75th percentile of percent body fat. Normal BMI defined as BMI-for-age〈85th percentile on CDC growth charts, overweight defined and BMI-for-age between the 85th and 95th percentiles on CDC growth charts, obese defined as BMI-for-age 〉=95th percentile on CDC growth charts.* Significantly different from non-Hispanic whites and Mexican Americans, ** Significantly different from Mexican Americans. Source: CDC/NCHS National Health and Nutrition Examination Surveys 1999–2004; Flegal et al. AJCN 2010.

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(p.92) boys (17.9%) and non-Hispanic black boys (15.7%) in the lowest PIR quintile compared to the highest quintile (11.2% and 11.1%). Among all boys (19.8%) and nonHispanic white boys (20.3%) in the 2nd lowest quintile the prevalence of obesity was higher compared to the highest PIR quintile (11.2% and 10.6%). Among girls, those in the lowest PIR quintile had a higher prevalence of obesity (18.5%) than all girls in the highest PIR quintile (10.7%). Nonetheless, there

Fig. 7.6 Prevalence of high adipositya by BMI category and race/ethnicity among girls 8–19 years, 1999–2004.aHigh adiposity defined as 〉=internal age and sex specific 75th percentile of percent body fat. Normal BMI defined as BMI-for-age〈85th percentile on CDC growth charts, overweight defined and BMI-for-age between the 85th and 95th percentiles on CDC growth charts, obese defined as BMI-for-age 〉=95th percentile on CDC growth charts. *Significantly different from non-Hispanic whites and Mexican Americans. Source: CDC/NCHS National Health and Nutrition Examination Surveys 1999–2004; Flegal et al. AJCN 2010.

Fig. 7.7 Prevalence of obesity* among boys 2–19 years, by education level of household head, 2003–2006.*Obesity defined as body mass index (BMI) 〉= sex and age specific 95th percentile from the 2000 CDC growth charts. Source: National Health and Nutrition Examination Surveys 1999–2008, NCHS, CDC; Ogden et al. 2010b.

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(p.93) were no significant trends reported (quadratic or linear) in the prevalence of obesity by PIR quintile (Ogden et al., 2010b). Similarly, the relationship between education of household head and obesity in children is inconsistent. Figs. 7.7 and 7.8 contain published results from NHANES 2003–2006 for boys and girls separately (Ogden et al., 2010b). The prevalence of obesity among non-Hispanic black girls in households where the head has greater than a high school education was significantly lower (19.4%) than the prevalence in households where the head only has a high school education (29.6%). This was the only significant difference in obesity prevalence between levels of household education among boys, girls, or any race/ethnic groups.

Fig. 7.8 Prevalence of obesity* among girls 2–19 years by education level of household head, 2003–2006.*Obesity defined as body mass index (BMI) 〉= sex and age specific 95th percentile from the 2000 CDC growth charts. **Significantly different from 〈high school group. Source: National Health and Nutrition Examination Surveys 1999–2008, NCHS, CDC; Ogden et al. 2010b.

Conclusion A strength of the NHANES study is that it contains actual measurements of weight, height, and percentage body fat. Measured weights and heights are more accurate than self-reported values of weight and height. Surveys and epidemiologic studies may not be conducted in-person due to cost, so height and weight are often self-reported rather than measured. Respondents tend to overestimate their heights and underestimate their weights. Or, in the case of children, parents may not know their child’s measurements or may under-estimate their child’s height (Akinbami & Ogden, 2009; Gorber et al., 2007). Measurement of body fat using DXA scans is more accurate than are calculations of body fat based on skin fold measurements (Steinberger et al., 2005). Although there were no significant linear trends in the prevalence of obesity among children and adolescents between 1999–2000 and 2007–2008, the prevalence remains high in the United States. Almost 17% of children and adolescents have a BMI-for-age〉=95th percentile of the sexspecific CDC growth charts and significant disparities remain by race/ethnicity. These disparities may in part reflect differences in adiposity between race/ethnic groups. Disparities by income and education are not consistent. References Bibliography references: Akinbami, L.J. & Ogden, C.L. (2009) Childhood overweight prevalence in the United States: the impact of parent-reported height and weight. Obesity 17(8), 1574–1580.

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Barlow, S.E. & Dietz, W.H. (1998) Obesity evaluation and treatment: Expert Committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services. Pediatrics 102(3), E29. CDC/NCHS. National Health and Nutrition Examination Survey. National Health and Nutrition Examination Survey. 2009. Chang, V.W. & Lauderdale, D.S. (2005) Income disparities in body mass index and obesity in the United States, 1971-2002. Archives of Internal Medicine 165(18), 2122–2128. Cassidy, C.M. (1991) The good body: when big is better. Medical Anthropology 13(3), 181–213. Flegal, K.M., Ogden, C.L., Yanovski, J., et al (2010) High adiposity and high BMI-for-age in US children and adolescents by race-ethnic group. American Journal of Clinical Nutrition 91(4), 1020–1026 Freedman, D.S., Katzmarzyk, P.T., Dietz, W.H., Srinivasan, S.R., & Berenson, G.S. (2009) Relation of body mass index and skinfold thicknesses to cardiovascular disease risk factors in children: the Bogalusa Heart Study. American Journal of Clinical Nutrition 90(1), 210–216. Gorber, S.C., Tremblay, M., Moher, D., & Gorber, B. (2007) A comparison of direct vs. selfreport measures for assessing height, weight and body mass index: a systematic review. Obesity Reviews 8(4), 307–326. Gortmaker, S.L., Must, A., Perrin, J., Sobol, M., & Dietz, W.H. (1993) Social and economic consequences of overweight in adolescence and young adulthood. New England Journal of Medicine 329(14), 1008–1012. Hamill, P.V., Drizd, T.A., Johnson, C.L., Reed, R.B., Roche, A.F., & Moore, W.M. (1979) Physical growth: National Center for Health Statistics percentiles. American Journal of Clinical Nutrition 32(3), 607–629. Hedley, A.A., Ogden, C.L., Johnson, C.L., Carroll, M.D., Curtin, L.R., & Flegal, K.M. (2004) Prevalence of overweight and obesity among US children, adolescents, and adults, 1999–2002. JAMA: the Journal of the American Medical Association 291(23), 2847–2850. Himes, J.H. & Dietz, W.H. (1994) Guidelines for overweight in adolescent preventive services: recommendations from an expert committee. The Expert Committee on Clinical Guidelines for Overweight in Adolescent Preventive Services. American Journal of Clinical Nutrition 59(2), 307–316. Krebs, N.F., Himes, J.H., Jacobson, D., Nicklas, T.A., Guilday, P., & Styne, D. (2007) Assessment of child and adolescent overweight and obesity. Pediatrics 120(Suppl 4), S193–S228. Kuczmarski, R.J., Ogden, C.L., Guo, S.S., et al. (2002) 2000 CDC Growth Charts for the United States: methods and development. Vital and Health Statistics 11(246), 1–190.

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Nathan, B.M. & Moran, A. (2008) Metabolic complications of obesity in childhood and adolescence: more than just diabetes. Current Opinion in Endocrinology, Diabetes, and Obesity 15(1), 21–29. Ogden, C.L., Flegal, K.M., Carroll, M.D., & Johnson, C.L. (2002) Prevalence and trends in overweight among US children and adolescents, 1999–2000. JAMA: the Journal of the American Medical Association 288(14), 1728–1732. Ogden, C.L., Carroll, M.D., Curtin, L.R., McDowell, M.A., Tabak, C.J., & Flegal, K.M. (2006) Prevalence of overweight and obesity in the United States, 1999–2004. JAMA: the Journal of the American Medical Association 295(13), 1549–1555. Ogden, C.L., Carroll, M.D., & Flegal, K.M. (2008) High body mass index for age among US children and adolescents, 2003–2006. JAMA: the Journal of the American Medical Association 299(20), 2401–2405. Ogden, C.L., Carroll, M.D., Curtin, L.R., Lamb, M.M., & Flegal, K.M. (2010a) Prevalence of high body mass index in US children and adolescents, 2007–2008. JAMA: the Journal of the American Medical Association 303(3), 242–249. Ogden, C.L., Connor, G.S., Rivera Dommarco, J., Carroll, M.D., Shields, M., & Flegal, K.M. (2010b) The epidemiology of childhood obesity in Canada, Mexico and the United States. In L. Moreno, I. Pigeot, & W. Ahrens (Ed.), Epidemiology of obesity in children and adolescents – prevalence and aetiology. New York: Springer. Sargent, J.D. & Blanchflower, D.G. (1994) Obesity and stature in adolescence and earnings in young adulthood. Analysis of a British birth cohort. Archives of Pediatrics and Adolescent Medicine 148(7), 681–687. Serdula, M.K., Ivery, D., Coates, R.J., Freedman, D.S., Williamson, D.F., & Byers, T. (1993) Do obese children become obese adults? A review of the literature. Preventive Medicine 22(2), 167– 177. Sobal, J. & Stunkard, A.J. (1989) Socioeconomic status and obesity: a review of the literature. Psychological Bulletin 105(2), 260–275. Steinberger, J., Jacobs, D.R., Raatz, S., Moran, A., Hong, C.P., & Sinaiko, A.R. (2005) Comparison of body fatness measurements by BMI and skinfolds vs dual energy X-ray absorptiometry and their relation to cardiovascular risk factors in adolescents. International Journal of Obesity 29(11), 1346–1352. Disclaimer: The findings and conclusions in this report are those of the authors and not necessarily of the agency.

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Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006 Jennifer A. O’Dea Michael J. Dibley

DOI:10.1093/acprof:oso/9780199572915.003.0008

Abstract and Keywords This chapter describes the relationships between obesity and overweight prevalence and gender, age, school year, school SES, and ethnicity among primary and secondary students from across Australia in cross sectional surveys conducted in 2000 and 2006. In the 2000 study, overweight and obesity — as defined by the IOTF international standard definition — were identified in 17.3% and 6.4% of participants, respectively. These characteristics showed a trend towards a greater prevalence among students from low-SES backgrounds compared with those from middle/high-SES backgrounds for the total group (19% v 16.8% overweight; 8.9% v 5.8% obese) and similar SES trends were found among females (19.7% v 17.2% overweight; 6.9% v 6.2% obese) and males (18.5% v 16.3% overweight; 9% v 5.5% obese). Similarly, in the 2006 study, around 6.8% of the children were obese and 18.5% were overweight. Prevalence of obesity by each ethnic group was as follows in the 2006 data set by ethnicity: East and South East Asian 3.6%, South Asian/Indian 4.9%, Anglo/Caucasian 5.9%, Southern European 8.9%, Aboriginal 10.1%, ‘Other’ 13.5%, Middle Eastern 15.8%, and Pacific Islander/Maori 25.6%. Compared to Anglo/Caucasian children, the odds risk (OR) for obesity was: 1.6 times greater for Southern European, 1.8 for Aboriginal, 2.5 for ‘Other’ participants who were mostly African refugees, 3.0 for Middle Eastern, and 5.5 for Pacific Islander children. Prevalence of obesity in 2006 for low, middle, and high school SES was 8.4, 7.2, and 3.7%, respectively, with corresponding ORs of 2.1 for middle SES and 2.4 for low SES compared to high SES. Finally, the analyses found that from 2000 to 2006, obesity increased among low SES schools from 5.8 to 8.6% compared to 5.5 to 6.3% in middle SES and 3.3 to 4.2% in high SES schools. The chapter discusses the increased need for assistance among low income and disadvantaged schools, and

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Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006

those with a varied ethnic mix to develop and implement culturally appropriate health promotion activities to prevent obesity.

Keywords: children, adolescents, epidemiology, Maori, culture, ethnic, school, social class, socioeconomic status, Australia

Chapter summary The purpose of this chapter is to describe the relationships between obesity and overweight prevalence and gender, age, school year, school socioeconomic status (SES), and ethnicity among primary and secondary students from across Australia in cross-sectional surveys conducted in 2000 and 2006. In the 2000 study, overweight and obesity, as defined by the IOTF international standard definition, were identified in 17.3% and 6.4% of participants, respectively. These characteristics showed a trend towards a greater prevalence among students from low-SES backgrounds compared with those from middle/high SES backgrounds for the total group (19% versus 16.8% overweight; 8.9% versus 5.8% obese) and similar SES trends were found among females (19.7% versus 17.2% overweight; 6.9% versus 6.2% obese) and males (18.5% versus 16.3% overweight; 9% versus 5.5% obese). Similarly, in the 2006 study, around 6.8% of the children were obese and 18.5% were overweight. Prevalence of obesity by each ethnic group was as follows in the 2006 data set by ethnicity: East and South East Asian 3.6%; South Asian/Indian 4.9%; Anglo/Caucasian 5.9%; Southern European 8.9%; Aboriginal 10.1%; ‘Other’ 13.5%; Middle Eastern 15.8%; and Pacific Islander/Maori 25.6%. Compared to Anglo/Caucasian children, the odds risk (OR) for obesity was: 1.6 times greater for Southern European; 1.8 for Aboriginal; 2.5 for ‘Other’ participants who were mostly African refugees; 3.0 for Middle Eastern; and 5.5 for Pacific Islander children. Prevalence of obesity in 2006 for low, middle, and high school SES was 8.4, 7.2, and 3.7%, with corresponding ORs of 2.1 for middle SES and 2.4 for low SES compared to high SES. Finally, our analyses found that from 2000 to 2006, obesity increased among low SES schools from 5.8 to 8.6% compared to 5.5 to 6.3% in middle SES and 3.3 to 4.2% in high SES schools. Discussion focuses on the increased need for assistance among low-income and disadvantaged schools, and those with a varied ethnic mix to develop and implement culturally appropriate health promotion activities to prevent obesity.

Introduction During the past three decades, the prevalence of overweight and obesity in children and adolescents has increased throughout the world (WHO, 2000). Among Australian children and adolescents the rise in overweight and obesity began in the 1980s and continued into the 1990s (Magarey et al., 2001). In an analysis of data from two national surveys of schoolchildren in 1985 and 1995, an average increase in obesity from 1.3% in 1985 to 5.0% in 1995 was found, as well as an increase in overweight from 10% to 15.4% respectively (Magarey et al., 2001). (p.96) The findings of another large national study of 4441 Australian schoolchildren conducted in 2000 (O’Dea, 2003; O’Dea & Wilson, 2006) reported overall obesity prevalence at 6.3% and overweight at 17.3%. Moreover, in the national study conducted in 2000, students of both sexes from low SES schools were significantly more likely to be obese (9.0% versus 5.8%) or overweight (19.0% versus 16.8%) and low SES predicted the risk of obesity (O’Dea, 2003).

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Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006

The recent study of NSW schoolchildren conducted in 2004 (Booth et al., 2007) reported an average of 6.2% obese (varying according to age group and gender from 3.6% to 7.2%) and 18.0% overweight (varying from 16.2% to 19.4%). Several early studies have reported an increased prevalence of obesity or overweight among children from low SES schools (O’Dea, 1994; O’Dea & Caputi, 2001; O’Dea, 2003) whereas other studies have not found this relationship (Booth et al., 2007; Li et al., 2007). The research question of the current set of Australian studies was ‘What is the association between social class and ethnicity upon the prevalence of overweight and obesity among boys and girls in Australia?’ The major aims of the studies were to examine the prevalence of obesity and overweight in recent samples of schoolchildren from across Australia, and to examine any associations between obesity and overweight and age, gender, school year, school SES and ethnicity. A second aim was to examine the change in prevalence between 2000 and 2006.

Methods Data in these studies were collected as part of the National Nutrition & Physical Activity Study in 2000 and the National Youth Cultures of Eating Study in 2006. The Youth Cultures of Eating Study was a 3-year, Australian Research Council funded study of health, weight, culture, and eating among 8492 schoolchildren from every state and territory of Australia. The primary aim of the two national studies was to examine the interrelationships between social class, gender, age, and ethnicity and how they are associated with obesity, body image, food consumption, and their cultural meanings. In the national study in 2000, children in school years 2–12 (aged 6–18 years) participated from randomly selected schools from lists of all state and territory’s schools in Australia. Public (government), private and Catholic schools, in both rural and urban areas, were represented. A total of 4441 students participated in the 2000 study. In the 2006 study, a total of 57 randomly selected primary and high schools were recruited from every state and territory of Australia and included children from government, private and Catholic schools. The same 32 schools that participated in 2000 also participated in 2006 and another 25 additional schools were also recruited. In both studies, the SES of schools was based on a direct federal government measurement of parental income (Commonwealth Department of Education, Science and Training, 2005). These SES categories were confirmed in an interview with researchers from each of the state or territory Departments of Education and each of the school principals in order to verify the SES of the majority of children attending the school. The questionnaire measured demographic details of gender, age, school SES, school class year (year 3–10), as well as many other food and nutrition related questions. Height and weight were measured in both surveys and the IOTF cut-offs were calculated to define overweight and obesity (Cole et al., 2000). In the 2006 study, participants were able to self report their ethnic/cultural background(s) from the following categories Anglo/Caucasian; Aboriginal/Torres Strait Islander; Southern European/ Mediterranean; Chinese/South East Asian; Middle Eastern/Arabic; Pacific Islander/Maori; Indian/Sri Lankan and Other.

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Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006

(p.97) In order to examine the relationships between overweight, obesity and gender, age, ethnicity, school SES, and school class year, unadjusted odds ratios and their 95% CIs were calculated in univariate analyses, and adjusted odds ratios and their 95% CIs were calculated in multivariate regression analyses. To adjust for the effect of the school-based cluster sampling, the Stata survey (‘svy’) commands was applied, which adjusted for similarities within school clusters by Taylor linearized variance estimation. All analyses were conducted using Stata version 10 (Stata Corp, 2007).

Results In the 2000 study, overweight and obesity, as defined by the IOTF international standard definition, were identified in 17.3% and 6.4% of participants, respectively. These characteristics showed a trend towards a greater prevalence among students from low SES backgrounds compared with those from middle/high SES backgrounds for the total group (19% versus 16.8% overweight; 8.9% versus 5.8% obese) and similar SES trends were found among females (19.7% versus 17.2% overweight; 6.9% versus 6.2% obese) and males (18.5% versus 16.3% overweight; 9% versus 5.5% obese). In the 2006 study, the relationship between overweight and obesity combined and obesity after modeling with gender, ethnicity, school SES, and school class year was examined and the results are given in Tables 8.1 and 8.2. Results in 2006 found a relationship between both ethnicity and school SES and the prevalence of overweight and obesity combined, and with obesity alone. The findings in Table 8.1 show that compared to Anglo/Caucasian children, Aboriginal Children were 1.8 times more likely to be obese; Southern European children were 1.6 times more likely to be obese; Middle Eastern children were 3.0 times more likely to be obese and Pacific Islander/Maori children were 5.5 times more likely to be obese. Children of ‘Other’ ethnicity, including African refugees from Somalia and Sudan, were 2.5 times more likely to be obese than Anglo/Caucasian children. The distribution of obesity prevalence by ethnic group in 2006 is illustrated in Fig. 8.1 below. In addition to the pattern of obesity by ethnicity, the analysis shown earlier in Table 8.2 found a clear relationship between school SES and obesity with children from middle SES schools being twice as likely to be obese and those from low SES schools being nearly two and a half times as likely to be obese than children from high SES schools. The graded effect of BMI by school SES is illustrated in Fig. 8.2, which compares BMI Z scores of children from low and high SES schools using the CDC 2000 Growth reference (Kuczmarkski et al., 2000) as a comparison. The BMI-for-age Z score distribution for children from low SES schools was shifted to higher BMI values than the children from high SES schools. However, BMI-for-age Z score distribution for children from high SES was also shifted to higher BMI values than in the CDC 2000 Growth reference. In both the studies conducted in 2000 and 2006, obesity was clearly distributed in a pattern related to school SES.

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Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006

This pattern is illustrated later in Fig. 8.3 and clearly shows that obesity prevalence stayed relatively unchanged among children from middle and high SES schools but increased in low SES schools.

Discussion The two prevalence studies conducted in Australia on a nationwide basis in 2000 and 2006 showed several trends that are extremely important in the planning and implementation of (p. 98)

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Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006

Table 8.1 Prevalence of overweight and obesity among Australian schoolchildren in 2006 using IOTF 0.5 year BMI cut-offs* Overweight

Obesity

Characteristic

Weighted N(a)

%

95% CI

All

1538

18.5

17.1

Boys

711

17.6

Girls

827

〈=8

Weighted N

%

95% CI

20.0

577

6.8

5.5

8.5

16.0

19.3

325

8.0

6.2

10.3

19.4

17.55

21.4

244

5.7

4.5

7.2

127

17.2

12.86

22.0

44

6.0

3.8

9.1

9

167

16.4

13.95

19.2

74

7.3

5.6

9.5

10

211

19.7

17.4

22.2

60

5.6

3.9

8.0

11

186

18.1

15.48

21.0

62

6.0

4.2

8.4

12

198

19.0

15.8

22.7

73

7.0

4.8

10.1

13

204

19.7

14.53

26.2

93

9.0

6.1

13.3

14

214

19.2

5.99

22.9

57

5.1

3.4

7.5

15

163

17.3

2.12

24.0

64

6.8

4.7

9.7

〉=16

69

21.4

15.26

29.1

42

13.0

8.5

19.5

Anglo Caucasian

1055

18.5

16.8

20.4

337

5.9

4.7

7.5

Aboriginal TSI

66

18.4

13.4

24.7

36

10.1

6.4

15.5

Southern European

163

22.6

17.9

28.2

64

8.9

6.3

12.5

East & Southeast Asian

129

16.7

11.2

24.2

28

3.6

2.3

5.6

Gender

Age (years)

Ethnicity

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Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006

Overweight

Obesity

Characteristic

Weighted N(a)

%

95% CI

Middle Eastern

24

20.2

12.3

Pacific Islander/Maori

38

18.2

South Asian/Indian

33

Other (Mainly African) Unknown

Weighted N

%

95% CI

31.3

19

15.8

9.3

25.6

12.3

26.0

53

25.6

16.3

37.8

16.7

11.6

23.5

10

4.9

2.5

9.6

5

7.1

2.7

17.6

10

13.5

7.4

23.3

25

15.2

11.4

11.4

11

6.8

3.3

13.5

Low SES

383

18.6

17.3

20.1

172

8.4

5.8

11.9

Middle SES

900

19.3

17.3

21.5

337

7.2

5.4

9.6

High SES

255

15.9

13.5

18.7

59

3.7

2.7

5.1

3

161

15.6

12.0

20.0

68

6.6

5.1

8.5

4

190

19.0

16.3

22.2

61

6.1

3.9

9.4

5

189

17.9

15.0

21.2

61

5.8

3.7

8.8

6

201

18.9

16.4

21.7

55

5.2

3.5

7.7

7

225

21.5

17.6

25.8

93

8.9

6.4

12.1

8

196

18.5

14.4

23.5

87

8.2

5.0

13.2

9

168

16.2

13.9

18.8

51

4.9

3.4

7.1

10

210

20.4

16.8

24.6

93

9.0

6.0

13.4

SES of school

Class year

(a)

Sampling weights were constructed to adjust the analyses to better represent the age, gender, and state distribution

of school-aged children in years 3 to 10 in schools across Australia in 2006 based on Australian Bureau of Statistics

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Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006

school enrolment data (ABS, 2006). (b)

Overweight and obesity were defined according to the International Obesity Task Force 0.5 year age references (Cole et al., 2000).

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Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006

(p.99)

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Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006

Table 8.2 Relationship between overweight and obesity combined, obesity and gender, ethnicity and school SES among schoolchildren in Australia in 2006 Obese(a)

Overweight & obese(a) combined Unadjusted OR (95% CI)

Adjusted(b) OR (95%CI)

Unadjusted OR (95% CI)

Adjusted(b) OR (95 %CI)

Girls

1.00

–

1.00

1.00

Boys

1.02 (0.87,1.20)

–

1.44 (1.13,1.82)

1.52 (1.20,1.92)

Anglo Caucasian

1.00

1.00

1.00

1.00

Aboriginal

1.23 (0.81,1.87)

1.17 (0.76,1.78)

0.470 1.78 (1.22,2.59)

1.66 (1.00,2.76)

0.052

Southern European

1.43 (1.01,2.00)

1.44 (1.06,1.96)

0.021 1.56 (0.97,2.50)

1.60 (1.05,2.44)

0.029

East & Southeast Asian

0.79 (0.49,1.27)

0.76 (0.47,1.24)

0.271 0.59 (0.36,0.98)

0.55 (0.33,0.91)

0.022

Middle Eastern

1.74 (1.06,2.84)

1.71 (1.06,2.76)

0.029 2.98 (1.68,5.27)

2.95 (1.63,5.36)

0.001

Pacific Islander/Maori

2.41 (1.78,3.27)

2.33 (1.74,3.13)

0.000 5.48 (3.61,8.31)

5.10 (3.34,7.78)

0.000

South Asian

0.86 (0.60,1.23)

0.84 (0.58,1.22)

0.350 0.83 (0.42,1.62)

0.86 (0.45,1.68)

0.660

Other

0.80 (0.43,1.49)

0.78 (0.42,1.46)

0.426 2.48 (1.13,5.45)

2.39 (1.10,5.21)

0.028

Unknown

0.87 (0.58,1.32)

0.80 (0.55,1.18)

0.256 1.16 (0.53,2.56)

0.89 (0.42,1.89)

0.755

High

1.00

1.00

Middle

1.48 (1.13,1.94)

1.50 (1.16,1.94)

0.003 2.02 (1.28, 3.20)

1.96 (1.25,3.07)

0.004

Low

1.51 (1.14,2.00)

1.51 (1.17,1.96)

0.002 2.37 (1.40,3.99)

2.36 (1.43,3.90)

0.001

Factors

P

P

Gender

0.001

Ethnicity

SES of school

(a)

1.00

1.00

Overweight and obesity were defined according to the International Obesity Task Force 0.5 year age references (Cole et al., 2000).

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Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006

(b)

Adjusted odd ratio and 95% CIs were calculated with multivariate regression analysis, using STATA ‘svy’ commands to adjust for similarities within school clusters by Taylor linearized variance estimation. All multivariate analyses were adjusted for age.

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Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006

(p.100) childhood obesity initiatives. First, the 2000 study, although suggesting no substantial increase in obesity since the 1995 national survey (5.1% obese in 1995; 6.3% in 2000), did suggest a problematic trend among children and adolescents from low SES schools, whose risk of obesity was greater than that of their more affluent peers. This finding was replicated in the 2006 study with an overall prevalence, after weighting the samples for actual 2006 school population numbers, of 6.8% obese and 18.5% overweight. These figures concur with those of other studies conducted among Australian children and adolescents

Fig. 8.1 Percentage distribution of obesity using International Obesity Task Force 0.5 year cutoff points among ethnic groups in Australia in 2006.

in 2000 (O’Dea, 2003; Goodman et al., 2002), 2004 (p.101)

Fig. 8.2 BMI-for-age Z score distribution by high and low school SES status of Australian schoolchildren in 2006 compared to CDC growth reference (N = 3724).

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Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006

(Booth et al., 2007), and 2003/2004 (Li et al., 2007) and are slightly greater than the overall number of 5.1% and 16% obese and overweight reported using national data from 1995 (Magarey et al., 2001). In both study years 2000 and 2006, we found a clear graded association between obesity and school SES with the risk of obesity increasing in 2006 by 2.1 among children from middle SES schools and 2.4 Fig. 8.3 Percentage distribution of obesity using International Obesity Task Force 0.5 for those from low SES schools compared to year cutoff points among children and those from high SES schools. The adolescents from low, middle and high SES prevalence of 8.4, 7.2, and 3.7% obese from schools in 2000 and 2006. children at low, middle, and high SES schools was consistent across the genders, and a similar pattern for overweight suggests a protective effect of higher social class on the weight status of children and adolescents. This finding supports previous suggestions that low SES increases the risk of overweight and obesity among Australian children and adolescents (O’Dea & Wilson, 2006; O’Dea & Caputi, 2001; O’Dea, 1994) and it also concurs with recent SES findings among children and adolescents from New Zealand (Goulding et al., 2007) as well as studies among adult populations (Freedman et al., 2002; Jebb et al., 2004). The finding that low and middle SES children are at greater risk of overweight and obesity should not be interpreted as a non-risk situation for higher SES children, as our results also show an increased BMI-for-age Z score among all three SES groups, indicating that Australian children from all social groups have become bigger than previous norms. The impact of ethnicity upon obesity risk was a convincing new finding of the 2006 study, with an odds ratio of 1.6 for Southern European, 1.8 for Aboriginal, 3.0 for Middle Eastern and 5.5 for Pacific Islander/Maori children and adolescents compared to their Anglo Caucasian peers. The greater risk of obesity and overweight among Maori and Polynesian children and adolescents, together with an increased incidence and prevalence of type 2 diabetes among these children has recently been reported by researchers in New Zealand (Goulding et al., 2007; Hotu et al., 2004). We agree with our New Zealand colleagues who have called for greater attention to be drawn to the need for identification and remedial treatment of obese young people and the implementation of successful strategies to curb severe adiposity and type 2 diabetes, particularly among adolescents of Pacific Islander, Middle Eastern, and Aboriginal origin who appear to be most at risk. Interestingly, the obesity risk was lower in 2006 for children of Asian, South East Asian, Indian, or Sri Lankan background when compared with Anglo Caucasian children, which may be a reflection of the known body composition differences and the need to use lower cut-offs for obesity among studies of Asian populations (Wang et al., 1994). Similarly, higher cut-offs may be required for (p.102) those of Polynesian descent as it is known that at higher BMI levels, Polynesians are significantly leaner than Europeans (Swinburn et al, 1999). The trend for

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Overweight, obesity, gender, age, ethnicity, and school SES among Australian schoolchildren in studies from 2000 and 2006

African refugees, mainly from Somalia and Sudan, to be more likely than their Caucasian peers to be obese was interesting and suggests that the transition to a country such as Australia, where food is plentiful, may result in a greater obesity risk among immigrant or refugee children. As a result of these long-term, cross-sectional studies, we recommend the implementation of culturally appropriate physical activity and nutrition promotion interventions, which should be particularly targeted at middle and low SES schools and ethnically diverse areas of Australia. We also recommend regular clinical screening of obese young people for type 2 diabetes risk, particularly those who are inactive, ethnically at risk, and those who have a family history of the disease.

Acknowledgements Many thanks to the State Departments of Education and school principals and students who participated in these two large national studies in 2000 and 2006. The 2000 study was funded by an independent Industry Research Grant from Kellogg Australia and the 2006 study was funded by a 3-year ARC Discovery grant from the Australian Research Council (ARC) to the University of Sydney, Probyn, E. & O’Dea, J. National Youth Cultures of Eating Study, 2005–2007. References Bibliography references: Australian Bureau of Statistics (2006) Schools Data Report 4221.0. ABS, Canberra. Booth, M.L., Dobbins, T., Okely, A.D., Denney Williams, E., & Hardy, L.L. (2007) Trends in the prevalence of overweight and obesity in young Australians 1985, 1997, 2004. Obesity 15, 1089– 1095. Cole, T.J., Bellizzi, M.C., & Flegal, K.M. (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320, 1240–1243. Commonwealth Department of Education, Science and Training (2005) Disadvantaged schools program: Operational Guidelines. Commonwealth Department of Education and Youth Affairs, AGPS, Canberra. Freedman, D.S., Kettel Khan, L., Serdula, M.K., Galuska, D.A., & Dietz, W.H. (2002) Trends and correlates of class 3 obesity in the United States from 1990 through 2000. JAMA: the Journal of the American Medical Association 288, 1758–1761. Goodman, S., Lewis, P.R., Dixon, A.J., & Travers, C.A. (2002) Childhood obesity: of growing urgency. Medical Journal of Australia 176, 400–401. Goulding, A., Grant, A.M., Taylor, R.W., Williams, S., Parnell, W.R., Wilson, N., et al. (2007) Ethnic differences in extreme obesity. Journal of Pediatrics 151, 542–544.

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Hotu, S., Carter, B., Watson, P.D., Cutfield, W.S., & Cundy, T. (2004) Increasing prevalence of type 2 diabetes in adolescents. Journal of Paediatrics & Child Health 40, 201–204. Jebb, S.A., Rennie, K.L., & Cole, T.J. (2004) Prevalence of obesity among young people in Great Britain. Public Health Nutrition 7, 461–465. Kuczmarkski, R.J., Ogden, C.L., & Grummer-Strawn, L.M. (2000) CDC Growth Charts: United States. Advance Data from Vital and Health Statistics; no.314. National Center for Health Statistics, Hyattsville, Maryland. Li, M., Byth, K., & Eastman, C.J. (2007) Childhood overweight and obesity by socioeconomic indicators by areas. Medical Journal of Australia 187, 195. Magarey, A.M., Daniels, L.A., & Boulton, T.J. (2001) Prevalence of overweight and obesity in Australian children and adolescents: reassessment of 1985 and1995 data against new standard international definitions. Medical Journal of Australia 174, 561–564. Erratum in: Medical Journal of Australia. 175, 392. O’Dea, J. (1994) Food habits, body image and self-esteem of adolescent girls from disadvantaged and non-disadvantaged backgrounds. Australian Journal of Nutrition & Dietetics. 51, 74–78. O’Dea, J.A. (2003) Differences in overweight and obesity among 4441 Australian schoolchildren of low and middle/high socioeconomic status. Medical Journal of Australia 179, 63. O’Dea, J. & Caputi, P. (2001) Socioeconomic, weight, age and gender interactions in the body image and weight control practices of 6–19 year old children and adolescents. Health Education Research 16, 521–532. O’Dea, J.A. & Wilson, R. (2006) Socio-cognitive and nutritional factors associated with body mass index in children and adolescents: possibilities for childhood obesity prevention. Health Education Research 21, 796–806. Stata Corp (2007) Data Analysis and Statistical Software, Version 10. College Station, Texas. Swinburn, B.A., Ley, S.J., Carmichael, H.E., & Plank, L.E. (1999) Body size and composition in Polynesians. International Journal of Obesity 23, 1178–1183. Wang, J., Thornton, J.C., Russell, M., Burastero, S., Heymsfield, S., & Pierson, R.N. Jr (1994) Asians have lower body mass index (BMI) but higher percent body fat than do whites: comparisons of anthropometric measurements. American Journal of Clinical Nutrition 60, 23–28. World Health Organisation (WHO). (2000) Obesity: preventing and managing the global epidemic. Report of a WHO consultation World Health Organization, Geneva.

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006 Zhaohui Cui Michael J. Dibley

DOI:10.1093/acprof:oso/9780199572915.003.0009

Abstract and Keywords This chapter reviews the secular trends in childhood obesity and associated risk factors from three nationwide surveys across China conducted between 1982 and 2006. The Chinese National Surveys on Students' Constitution and Health (CNSSCH) have been conducted every five years since 1985. To date, it is the largest nutrition and health survey of a nationally representative sample of school-age children and adolescents in China. All the subjects were primary or high school students aged 7–18 years randomly selected from each of the mainland provinces, excluding Tibet. The China National Nutrition (and Health) Surveys (CNNHS) are nationally representative cross-sectional surveys conducted in 1982, 1992, and 2002; and include dietary intake data in 1982, 1992, and 2002 and physical activity information in 2002. The survey is a longitudinal study conducted in eight provinces in 1991, 1993, and 1997; and nine provinces in 2000, 2004, and 2006. The average interval between surveys was three years. For CNSSCH, the 2000 weight for height screening criteria in Chinese children and adolescents was used to define childhood overweight and obesity. For the same age-, sex-, and heightgroup, a child with body weight equal to or more than 110% of the reference body weight was categorized as overweight, and a child with body weight equal to or more than 120% of the reference body weight was categorized as obesity. The age- and sex-specific BMI cut-offs recommended by the International Obesity Task Force (IOTF) were used in CNNHS and CHNS. The prevalence of childhood overweight and obesity in China has increased dramatically over last three decades, especially in boys in urban areas. Parallel with the increasing prevalence of childhood obesity has been a decline in the intake of dietary energy and vegetables, and an increase in the intake of dietary fat and animal foods among Chinese children. In 2002, the

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

proportion of children who reported regular exercise was very low while the level of reported sedentary activity was high.

Keywords: overweight, obesity, children, adolescents, epidemiology, China, risk factor, BMI

Chapter summary The purpose of this chapter is to review the secular trends in childhood obesity and associated risk factors from three nationwide surveys across China conducted between 1982 and 2006. The Chinese National Surveys on Students’ Constitution and Health (CNSSCH) have been conducted every 5 years since 1985. To date, it is the largest nutrition and health survey of a nationally representative sample of school-age children and adolescents in China. All the subjects were primary or high school students aged 7–18 years randomly selected from each of the mainland provinces, excluding Tibet. The China National Nutrition (and Health) Surveys (CNNHS) are nationally representative cross-sectional surveys conducted in 1982, 1992, and 2002, and include dietary intake data in 1982, 1992, and 2002 and physical activity information in 2002. The survey is a longitudinal study conducted in eight provinces in 1991, 1993, and 1997 and nine provinces in 2000, 2004, and 2006 in China. The average interval between surveys was 3 years. For CNSSCH, the 2000 weight for height screening criteria in Chinese children and adolescents were used to define childhood overweight and obesity. For the same age, sex, and height group, a child with body weight equal to or more than 110% of the reference body weight was categorized as overweight, and a child with body weight equal to or more than 120% of the reference body weight was categorized as obese. The age- and sex- specific BMI cut-offs recommended by the International Obesity Task Force (IOTF) were used in CNNHS and CHNS. To compare CNSSCH, CNNHS and CHNS, the age- and sex- specific BMI cut-offs recommended by the Group of China Obesity Task Force were used. The prevalence of childhood overweight and obesity in China has increased dramatically over the last three decades, from rare cases in 1982 to a significantly increased number in 2005– 2006, especially in boys in urban areas. Parallel with the increasing prevalence of childhood obesity has been a decline in the intake of dietary energy and vegetables, and an increase in the intake of dietary fat and animal foods among Chinese children. In 2002, the proportion of children who reported regular exercise was very low whereas the level of reported sedentary activity was high.

Introduction As a result of rapid economic development, urbanization, and modernization, lifestyles of Chinese people are undergoing a rapid nutrition transition. For example, from 1982 to 2002, the average consumption of animal foods per reference man per day increased from 53 g to 132 g, but in contrast, the consumption of cereal and vegetables dropped from 510 g and 316 g to 402 g and (p.105) 276 g (Zhai et al., 2005), respectively. At the same time, labour-saving facilities, such as computers, lifts, and automobiles have been flooding into people’s lives. Exposed to such

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

an obesogenic environment, the prevalence of obesity in both adults and children has dramatically increased over the last few decades. Childhood is an important life cycle period for the prevention and control of this obesity epidemic. To prevent obesity in childhood, an understanding of the trends in the prevalence of obesity, and the risk factors for excess weight gain in childhood is critical. In this chapter, the authors have reviewed the trends in childhood obesity and their associated risk factors based on three nationwide surveys in China.

Data sources There have been three recent nationwide surveys related to childhood obesity in China: the China National Surveys on Students’ Constitution and Health; the China National Nutrition and Health Surveys; and the China Health and Nutrition Surveys. Even though these three surveys were conducted by different organizations and for different purposes, they remain valuable sources of data about trends in childhood obesity in China. In the following sections each survey and the relevant methodology are briefly described. 1 The China National Surveys on Students’ Constitution and Health (CNSSCH) The CNSSCH surveys were jointly initiated by the Ministry of Education, the Ministry of Health, the Ministry of Science and Technology, the State of Nation Affairs, and the State Sports General Administration, People’s Republic of China, and have been conducted every 5 years since 1985. To date, it is the largest nutrition and health survey of a nationally representative sample of school-age children and adolescents in China. All the subjects are primary or high school students aged 7–18 years randomly selected from each of the mainland provinces, excluding Tibet, where the Han people are a minority. All subjects in this study had lived in the sample areas for at least 1 year, and belonged to the Han nationality, which accounts for 92% of the total Chinese population. The sample was stratified by sex and area of residence giving four populations of urban and rural males and females in each province and the municipalities directly affiliated with the central government. Each of these strata has an equal sample from three socioeconomic classes (‘upper’, ‘moderate’, and ‘low’). The criteria for defining the socioeconomic class strata were based on five indices: regional gross domestic product, total yearly income per capita, average food consumption per capita, natural growth rate of population, and the regional social welfare index, all of which were province specific. The survey participants had a thorough medical examination before measurement, and were generally free from overt diseases or physical or mental disorders (Ji & Cheng, 2008). In each of the sex–age subgroups in each province, there were 294 to 312 subjects in 1985, 101 to 118 subjects in 1991, 147 to 161 subjects in 1995 and 2000, and 155 to 167 subjects in 2005. In total there were 409,946 subjects (205,100 males and 204,846 females) in 1985, 140,604 subjects (70,621 males and 69,983 females) in 1991, 216,373 subjects (103,112 males and 113,261 females) in 1995, 214,796 subjects (107,482 males and 107,314 females) in 2000, and 226,602 subjects (113,749 males and 112,853 females) in 2005. 2 China National Nutrition (and Health) Surveys (CNNHS) The CNNHS are nationally representative cross-sectional surveys conducted respectively in 1982, 1992, and 2002, i.e. 1982 China National Nutrition Survey (1982 CNNS), 1992 China

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

National Nutrition Survey (1992 CNNS), and 2002 China National Nutrition and Health Survey (2002 CNNHS) (Li et al., 2008). The 1982 CNNS covered 24 provinces and three municipalities, all administrative units (except Zhejiang province and Taiwan) directly under the control of central government with the exception of Tibet. The 1992 CNNS and 2002 CNNHS covered all provinces, autonomous regions, and the (p.106) municipalities directly affiliated to the central government (Hong Kong, Macao, and Taiwan were not included). A multistep cluster sampling method was used for subject selection. There were 10,127 subjects (5,334 males and 4,793 females) aged 7–17 in 1982, 15,501 (8,048 males and 7,453 females) in 1992, and 44,880 (23,242 males and 21,638 females) in 2002. 3 China Health and Nutrition Survey (CHNS) The CHNS is a longitudinal study conducted in eight provinces with repeated measurements in 1991, 1993, and 1997 and nine provinces in 2000, 2004, and 2006 in China (Fig. 9.1). Although the CHNS are not nationally representative surveys, the provinces included vary substantially in geography, economic development, and health indicators. A multistage random-cluster sampling process was used to select the sample surveyed in each of the provinces. Four counties within each province (one low-, two middle- and one high-income county defined on the basis of per capita income) were randomly selected using a weighted sampling scheme. In addition, the provincial capital and a lower-income city were selected when feasible. In two provinces, other large cities were selected because the provincial capitals were not available. The township capital and three villages within the counties and urban and suburban neighbourhoods within the cities were subsequently randomly selected. Finally, 20 households were randomly selected within each neighbourhood and all individuals in each household were interviewed. Only the results for subjects aged 7–17 years have been included in this chapter. There were 2,581 subjects (1,333 males and 1,248 females) in 1991, 2,392 subjects (1,248 males and 1,144 females) in 1993, 2,389 subjects (1,269 males and 1,120 females) in 1997, 2,290 subjects (1,216 males and 1,074 females) in 2000, 1,463 subjects (770 males and 693 females) in 2004, and 1,174 subjects (626 males and 548 females) in 2006. More information about this study can be found at the investigators’ website http://www.cpc.unc.edu/projects/china.

Definition of childhood obesity For CNSSCH, the 2000 weight-for-height screening criteria in Chinese children and adolescents (Department of Sport, Health, and Art Education, Ministry of Education of China, 2002) were

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

(p.107) used to define childhood overweight and obesity. For the same age, sex, and height group, a child with body weight equal to or more than 110% of the reference body weight was categorized as overweight, and a child with body weight equal to or more than 120% of the reference body weight was categorized as obese. In the CNNHS and the CHNS surveys, the age- and sex- specific BMI cut-offs recommended by the International Obesity Task Force (IOTF) were used (Cole et al., 2000). To compare CNSSCH, CNNHS and CHNS, the age- and sex- specific BMI cutoffs recommended by the Group of China Obesity Task Force were used (Group of China Obesity Task Force, 2004).

Fig. 9.1 Map of the survey regions in the China Health and Nutrition Survey (The darker shaded regions in the map are the provinces in which the survey was conducted: Heilongjiang, Liaoning, Shandong, Jiangsu, Henan, Hubei, Hunan, Guizhou, and Guangxi).

Statistical analysis As there are no available published data on national trends in risk factors for childhood obesity (e.g. dietary energy, fat, animal foods, vegetables, and fruits) in China, published crude data by age (7∼, 11∼, 14∼, 17), gender, and region (urban and rural) in 1992 and 2002 (Zhai & Yang, 2006) were standardized according to the Fifth National Population Census (China National Bureau of Statistics, 2000) to obtain average intake of children aged 7–17 by region. For CHNS, the released data (See http://www.cpc.unc.edu/projects/china) was used to conduct the analysis. The prevalence of overweight and obesity in each survey was calculated by age group, sex, urban or rural residence because of the essential differences in growth patterns by age, sex and region. To take account of the within-subject correlation from repeated measurements across surveys, generalized estimating equation analysis was performed to assess the changes in BMI during the study period after adjusting for age, sex, region and income. All the analyses were conducted using SAS (Version 9; SAS Institute, Cary, NC, USA). Trends in childhood obesity in China 1 Data from CNSSCH (CNSSCH Association, 2007 ) The prevalence of overweight in urban Chinese boys has steadily increased since 1985, but the trend has accelerated since 1995, especially in the 7–12-year age group, which reached a prevalence of overweight of approximately 20% in 2005. At the same time, the prevalence of obesity increased quickly from around 0.2% in 1985 to about 12% in 2005 (See Table 9.1). The prevalence of overweight in rural Chinese boys increased slowly between 1985 and 1995. The increasing trend in overweight accelerated from 1995, reaching around 8% in 2005. The prevalence of obesity in this group rose slowly from 1985 to 2005 (See Table 9.2).

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

The prevalence of overweight and obesity in urban Chinese girls increased slowly from 1985 to 2005. This increasing trend in overweight and obesity in the past two decades was slower than for urban Chinese boys. In 2005, the prevalence of overweight and obesity in urban Chinese girls reached approximately 10% and 6%, respectively (See Table 9.3).

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

Table 9.1 Trends in overweight* and obesity* in urban Chinese boys (%)† Age (years)

Overweight

Obesity

1985

1995

2000

2005

1985

1995

2000

2005

7–9

1.72

8.13

12.25

25.12

0.12

5.88

8.55

11.69

10–12

1.32

6.63

14.48

16.62

0.41

8.92

11.59

15.33

13–15

1.15

5.10

10.68

11.63

0.32

6.74

9.51

12.09

16–18

1.09

4.72

11.28

11.36

0.05

3.63

8.79

10.57

* Overweight and obesity were defined by the 2000 weight-for-height screening criteria for Chinese children and adolescents. †

Modified from CNSSCH Association, 2007.

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

(p.108)

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

Table 9.2 Trends in overweight* and obesity* in rural Chinese boys (%)† Age (years)

Overweight

Obesity

1985

1995

2000

2005

1985

1995

2000

2005

7–9

2.23

2.93

6.03

8.67

0.86

1.24

3.08

5.37

10–12

3.34

4.32

7.72

10.78

1.37

2.08

4.30

7.09

13–15

3.45

5.12

6.10

7.32

0.97

1.82

3.40

5.35

16–18

4.21

3.17

6.69

6.69

0.65

1.22

3.19

4.09

* Overweight and obesity were defined by the 2000 weight-for-height screening criteria for Chinese children and adolescents. †

Modified from CNSSCH Association, 2007.

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

The prevalence of overweight and obesity in rural Chinese girls increased slowly from 1985 to 2005. In 2005, the prevalence of overweight and obesity in this sub-group was about 7% and 3%, respectively (See Table 9.4). In summary, these surveys have revealed that in 1985 the prevalence of childhood overweight and obesity in both urban and rural areas in China was very low (close to zero). At that time there was no evidence of an increase in childhood overweight and obesity. However by 2005 childhood obesity had become a serious public health problem in urban areas, especially for boys. Despite overweight and obesity in rural areas, especially in girls, being very low in 1985, the prevalence has continued to increase. This steadily increasing prevalence of overweight and obesity in a large population which has fewer resources and capacity to deal with future obesityrelated disease burdens, compared to their urban counterparts, indicates a strong need to develop programmes to prevent childhood obesity in this population. Finally the results indicate that in China, the increase in childhood overweight and obesity started earlier in urban than in rural child populations, and is more pronounced in boys than in girls. The sequence of appearance of childhood overweight and obesity has been urban boys first, followed by urban girls, then rural boys, and ending with rural girls. 2 Data from CNNHS 2.1 Overall trends The prevalence of overweight and obesity among Chinese children aged 7–17 years increased from 1.3% in 1982, to 4.4% in 1992 and reached 5.2% in 2002, a three-fold increase over 20 years. The overweight prevalence among Chinese children aged 7–17 years steadily increased from 1.2% in 1982, to 3.7% in 1992, and to 4.4% in 2002. Also, the prevalence of overweight steadily increased from 1982 to 2002 in each of age–sex subgroups except girls aged 7–12 years. In this later subgroup the obesity prevalence increased from 0.2% in 1982 to 0.9% in 1992, but then remained steady until 2002.

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

Table 9.3 Trends in overweight* and obesity* in urban Chinese girls† Age (years)

Overweight

Obesity

1985

1995

2000

2005

1985

1995

2000

2005

7–9

2.03

5.66

9.43

10.74

0.55

2.32

4.12

5.18

10–12

2.83

7.66

10.96

12.53

0.80

4.04

6.18

8.08

13–15

3.49

6.02

8.88

9.59

0.64

3.91

4.86

6.33

16–18

2.94

4.25

5.88

5.85

0.33

1.58

3.22

3.69

* Overweight and obesity were defined by the 2000 weight-for-height screening criteria for Chinese children and adolescents. †

Modified from CNSSCH Association, 2007.

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

(p.109)

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

Table 9.4 Trends in overweight* and obesity* in rural Chinese girls (%)† Age (years)

Overweight

Obesity

1985

1995

2000

2005

1985

1995

2000

2005

7–9

2.03

2.67

5.33

7.18

0.55

0.74

2.20

2.97

10–12

2.83

5.14

6.83

8.84

0.80

1.64

2.57

4.24

13–15

3.49

5.30

5.64

7.79

0.64

1.74

2.72

3.07

16–18

2.94

3.93

4.81

4.80

0.33

0.76

1.56

1.63

* Overweight and obesity was defined by the 2000 weight for height screening criteria in Chinese children and adolescents. †

Modified from CNSSCH Association, 2007.

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

2.2 Trends by sex–age subgroups The obesity prevalence among Chinese children aged 7–12 years fluctuated from 1982 to 2002. For boys, the prevalence of obesity increased from 0.3% in 1982 to 1.5% in 1992, but in the following 10 years from 1992 to 2002, the obesity prevalence remained unchanged, 1.5% in 1992 and 1.4% in 2002. For girls, however, the obesity prevalence increased from 0.2% in 1982 to 1.4% in 1992, and then decreased to 0.7% in 2002. The prevalence in both overweight and obesity among boys increased more than that among girls from 1982 to 2002 (See Table 9.5). 2.3 Regional Trends The trends by region and sex in prevalence of overweight and obesity among Chinese children aged 7–17 years from 1992 to 2002 are shown in Fig. 9.2. The prevalence in overweight and obesity in urban areas increased more than in rural areas. The fastest increase in the prevalence of

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

Table 9.5 Overweight and obesity prevalence1,2 among Chinese children in 1982, 1992, and 2002 (%)3 Gender

Age (y)

1982

1992

2002

Overweight

Obesity

Overweight

Obesity

Overweight

Obesity

7–12

1.7

0.3

3.9

1.5

5.0

1.4

13–17

0.5

0.1

3.7

0.4

4.6

0.7

Total

1.1

0.2

3.8

1.0

4.9

1.1

7–12

1.3

0.2

3.9

1.4

3.3

0.7

13–17

1.2

0.0

3.0

0.1

4.6

0.5

Total

1.3

0.1

3.5

0.8

3.9

0.6

7–12

1.5

0.2

3.9

1.4

4.2

1.1

13–17

0.8

0.1

3.4

0.2

4.6

0.6

Total

1.2

0.2

3.7

0.9

4.4

0.9

Boys

Girls

Total

1

Overweight and obesity defined using International Obesity Task Force standards;

Fifth National Population Census from unadjusted values in Li et al., 2008. 3

Modified from Li et al., 2008.

Page 15 of 25

2

The prevalence was age standardized according to the

Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

(p.110) overweight and obesity was observed among boys in urban areas, a 36.9% increase from 8.4% in 1992 to 11.5% in 2002. There was no trend observed among girls in rural areas. 3 Data from CHNS 3.1 Changes in mean BMI from 1991 to 2006 The mean BMI, after adjusting for age, sex, region, and income level increased from 17.4 kg/m2 in 1991, to 17.6 kg/m2 in 1993, to 17.7 kg/m2 in 1997, to 17.7 kg/m2 in 2

2000, to 18.2 kg/m in 2004, and reached18.3 kg/m2 in 2006 (See Fig. 9.3). (p.111)

Fig. 9.2 Comparison of overweight and obesity1,2 among Chinese children aged 7–17 years in 1992 and 2002, by gender and urban/rural populations. 1

Overweight and obesity defined using International Obesity Task Force standards; 2

Prevalence was age standardized according to the Fifth National Population Census from unadjusted values in Li et al., 2008.

Fig. 9.3 Changes in adjusted mean BMI among Chinese children aged 7–17 years from 1991 to 2006.

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

Table 9.6 Trends in overweight and obesity among Chinese children aged 7–17 years from 1991 to 2006 using IOTF cut-offs Overweight

Obesity

1991

1993

1997

2000

2004

2006

1991

1993

1997

2000

2004

2006

Urban

6.1

6.7

6.2

9.5

11.2

12.5

1.7

1.3

1.6

2.4

4.2

7.4

Rural

2.6

4.6

4.9

6.2

7.4

9.1

1.1

1.7

2.2

1.7

2.5

4.4

7–12

4.0

6.6

6.4

7.3

10.4

10.8

1.8

2.5

2.6

3.1

3.7

6.7

13–17

2.8

3.0

3.4

6.8

6.6

9.0

0.5

0.2

1.1

0.4

2.3

3.1

All

3.5

5.1

5.3

7.1

8.4

10.1

1.3

1.6

2.0

1.9

3.0

5.3

Urban

4.7

5.2

6.0

4.8

9.4

7.4

1.3

3.1

0.9

1.6

4.2

5.7

Rural

3.8

3.9

4.6

4.7

6.4

5.9

1.5

1.4

1.1

1.2

2.9

4.0

7–12

4.3

5.3

6.3

6.0

10.2

8.8

2.3

2.9

1.5

1.4

4.2

6.0

13–17

3.6

2.7

3.0

3.3

4.2

3.1

0.4

0.4

0.5

1.2

2.4

2.6

All

4.0

4.2

5.0

4.7

7.4

6.4

1.4

1.8

1.1

1.3

3.3

4.6

Urban

5.4

6.0

6.1

7.2

10.3

10.0

1.5

2.2

1.3

2.0

4.2

6.6

Rural

3.2

4.2

4.8

5.5

6.9

7.7

1.3

1.6

1.7

1.5

2.7

4.3

7–12

4.2

6.0

6.4

6.7

10.3

9.9

2.0

2.7

2.1

2.3

3.9

6.4

13–17

3.2

2.8

3.2

5.1

5.5

6.2

0.4

0.3

0.8

0.8

2.3

2.9

All

3.8

4.7

5.1

6.0

7.9

8.3

1.4

1.7

1.6

1.6

3.1

4.9

Boys

Girls

Total

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

3.2 Changes in the prevalence of overweight and obesity from 1991 to 2006 The changes in the prevalence of overweight and obesity from 1991 to 2006 according to age and region are shown in Table 9.6. There was an increasing trend in the overall prevalence of overweight and obesity among Chinese children. For boys, the prevalence of both overweight and obesity has continually increased during this period. For girls, the prevalence of obesity increased from 1.4% in 1991 to reach 4.6% in 2006, but only the prevalence of overweight among girls aged 7–12 years rose during this period, whereas there was no increase observed among girls aged 13–17 years. For both boys and girls, the largest changes in the prevalence of overweight and obesity were among the urban subgroup aged 7–12 years. In 2006, the highest prevalence of obesity was also observed in this subgroup, 13.8% for boys and 6.2% for girls, respectively. 3.3 Prevalence of overweight and obesity in urban and rural areas, and in boys and girls Table 9.6 also provides the data to compare the prevalence of overweight plus obesity between urban and rural areas, and boys and girls, respectively. In each survey year, the prevalence of overweight plus obesity in urban areas was higher than in rural areas (6.9% versus 4.5% in 1991, 8.2% versus 5.8% in 1993, 7.4% versus 6.5% in 1997, 9.2% versus 7.0% in 2000, 14.5% versus 9.6% in 2004, and 16.6% versus 12.0% in 2006), and was higher in boys than girls (4.8% versus 5.4% in 1991, 6.7% versus 6.0% in 1993, 7.3% versus 6.1% in 1997, 9.0% versus 6.0% in 2000, 11.4% versus 10.7% in 2004, and 15.4% versus 11.0% in 2006). The prevalence of overweight plus obesity shows a steadily increasing trend in each region and for each gender. (p.112) Table 9.7 Comparison of prevalence of obesity BMI among 2000 CHNS, 2000 CNSSCH, and 2002 CNNHS using Chinese1 cut-offs (%) Urban boys

Urban girls

Rural boys

Rural girls

2000 CHNS

3.7

3.8

3.1

2.5

2000 CNSSCH

4.4

2.3

1.5

1.0

2002 CNNHS

5.2

3.4

1.6

1.1

1

Obesity defined using Chinese age- and sex- specific BMI cutoffs (Group of China Obesity Task Force, 2004). 3.4 Comparison among CNSSCH, CNNHS, and CHNS Table 9.7 compares the prevalence of obesity in children aged 7–17 years by gender and region in the 2000 CHNS, with the results from two nationally representative surveys, the 2000 CNSSCH and the 2002 CNNHS. The prevalence of obesity in the 2000 CHNS (3.1% for boys and 2.5% for girls) was twice as high as that reported for the 2000 CNSSCH (1.5% for boys and 1.0% for girls) and the 2002 CNNHS (1.6% for boys and 1.1% for girls) in the rural areas, but similar for urban areas (for boys: 3.7% in CHNS versus 4.4% in CNSSCH versus 5.2% in CNNHS; for girls: 3.8% in CHNS versus 2.3% in CNSSCH versus 3.4% in CNNHS). As expected the prevalence of childhood overweight and obesity in these three surveys was slightly different. Both the 2000 CNSSCH and the 2002 CNNHS covered all 31 provinces,

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

autonomous regions, and municipalities in China including economically less well-developed regions in Western China. In contrast, the CHNS surveys were restricted to nine provinces, which although are widely dispersed across China, are not a nationally representative sample. In addition, the population in the CNSSCH were Han students, whereas those in the CNNHS and CHNS were any children aged 7–17 years, including both school students and children not attending school.

Status and changes in risk factors 1 Trends in dietary factors As seen in Table 9.8, the dietary energy intake of Chinese children decreased from 2199.7 Kcal/d in 1992 to 1968.4 Kcal/d in 2002. This drop in energy intake was greater in urban than in rural areas, especially for urban boys in whom a 421.5 Kcal/d reduction was observed. An average increase of 16.5 g/d in dietary fat intake in Chinese children was observed from 1992 to 2002. The increase in dietary fat intake of children in rural areas was more than in urban areas, especially for rural boys, in whom a 21.0 g/d increase was observed. An increased intake in animal foods was found in all groups (urban boys, urban girl, rural boys, and rural girls) in Chinese children from 1992 to 2002. During the 10-year period, an average of 30.6 g/d increase in animal foods was observed. The increase for rural children was 37.0 g/d, which was considerably greater than the 10.5 g/d increase for urban children. The intake of vegetables in Chinese children has dropped by 50.1 g/d, from 279.7 g/d in 1992 to 229.6 in 2002. The vegetable intake in urban children decreased more than in rural children. There was a slight drop in fruit intake of 2.2 g/d in boys but an increase of 5.4 g/d in girls. 2 Status in physical activity There are no nationally representative trend data available for physical activity levels in children, and to fill this information gap the physical activity data from the 2002 CNNHS (Ma & Kong, 2006) are presented. The 2002 CNNHS found that 4.7% of children aged 6–12 years and 8.1% of age 13–17 years participated in regular exercise in leisure time. More children aged 13–17 years reported regular (p.113)

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

Table 9.8 Trend in risk factors of obesity in Chinese children from 1992 to 2002 Boys

Girls

Total

1992

2002

1992

2002

1992

2002

Urban

2373.8

1952.3

2061.5

1713.1

2222.0

1836.0

Rural

2298.7

2115.0

2075.4

1893.9

2192.7

2010.0

Total

2316.4

2076.7

2072.0

1849.9

2199.7

1968.4

Urban

69.5

77.5

61.4

67.9

65.6

72.8

Rural

44.0

65.0

39.5

57.3

41.9

61.4

Total

50.0

68.0

44.8

59.9

47.6

64.1

Urban

160.2

171.6

138.1

147.6

149.4

159.9

Rural

62.2

102.8

53.3

86.3

58.0

95.0

Total

85.3

119.0

74.0

101.2

79.9

110.5

Urban

276.2

204.1

255.9

189.7

266.4

197.1

Rural

290.4

246.5

276.7

232.4

283.9

239.8

Total

287.1

236.5

271.7

222.0

279.7

229.6

Urban

75.6

67.3

70.1

75.4

72.9

71.2

Rural

41.8

41.5

37.1

42.5

39.6

42.0

Energy (Kcal/d)

Fat (g/d)

Animal foods (g/d)

Vegetable (g/d)

Fruits (g/d)

Page 20 of 25

Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

Boys

Total

Girls

Total

1992

2002

1992

2002

1992

2002

49.8

47.6

45.1

50.5

47.6

49.0

Prevalence was age-, sex-, and urban -rural standardized according to the Fifth National Population Census?

Page 21 of 25

Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

exercise than those aged 6–12 years. Also, the proportion of children participating in regular physical activity in urban areas was higher than those in rural areas (See Fig. 9.4). Chinese children reported an average 5.2 school days in a week, and children spent progressively more days at school in higher school grades. There was no substantial difference in the reported number of school days between urban and rural areas. Chinese children spent 1.4 hours in a school day for homework, and this progressively increased when children went to higher school grades. Children in urban areas spent more time on homework than those in rural areas (See Table 9.9). As seen in Fig. 9.5, about 95% of children aged 6–12 year and 93% of children aged 13–17 years reported participating in sedentary activities in leisure time. The proportion of children in urban areas participating in sedentary activities was slightly higher compared to children in rural areas. For children participating in sedentary activity, those aged 6–12 years spent 2.2 hours/day in sedentary activity, whereas children aged 13–17 years spent 2.5 hours/day (See Fig. 9.6). (p. 114)

Conclusions The prevalence of childhood overweight and obesity in China has increased dramatically in the last three decades, from rare cases in 1982 to an increased number in 2005–2006, especially in boys in urban areas. Based on the prevalence of overweight and obesity in 2002, we estimate that there are over 12 million overweight and obese children in China. In urban areas, effective preventive interventions should be implemented urgently with a multi-sector collaboration (p.115)

Fig. 9.4 The proportion of children attending regular exercise in China*, A. Boys, B. Girls, and C. Total.* Regular exercise: ≥ 3 times/week and ≥ 30 minutes each time.

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

Table 9.9 School days and time spent on homework in Chinese children Urban

Rural

Total

Primary school students

5.1

5.1

5.1

Junior high school students

5.4

5.3

5.3

Senior high school students

5.5

5.6

5.6

Total

5.3

5.2

5.2

Primary school students

1.4

1.2

1.2

Junior high school students

1.8

1.5

1.6

Senior high school students

2.0

1.7

1.8

Total

1.6

1.3

1.4

School days per week

Homework (Hours/school day)

(p.116) including education, health, and local government. Attention also should be paid to children, especially to boys, living in rural areas, considering their increasing trend in childhood overweight and obesity, the large population, the future costs of obesity-related chronic diseases, the poor affordability, and limited health resources in these areas. In parallel with the increasing prevalence of childhood obesity has been a decline in dietary energy intake of children most probably in response to declining levels of physical activity. However the increasing BMI indicates that this decline in total energy intake has not matched the decline in levels of physical activity. Although there are no data for secular trends in physical activity, the cross-sectional data in 2002 CNNHS indicated that the proportion of children who reported taking regular exercise was very low whereas the proportion reporting sedentary activity was high. The intake of dietary fat, animal foods increased, and vegetable intake dropped in Chinese children. Future interventions should include measures to limit animal food intake and encourage vegetable intake.

Fig. 9.5 Prevalence of sedentary activity participants in Chinese children* by urban and rural populations. * Sedentary activity includes TV viewing, reading, using computer, and playing video game in leisure time.

Fig. 9.6 Time (hours/day) spent on sedentary activity in leisure time by Chinese children.* * Sedentary activity includes TV viewing, reading, using computer, and playing video game in leisure time.

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

In conclusion, the continuing increase in overweight and obesity among China’s youth suggests more open to effective interventions are needed to halt or even reverse its progress. Achieving this will require a coordinated effort from policy makers, health professionals, schools, and family members for strategies to promote physical activity, healthy diets, and ultimately, a healthy body weight.

Acknowledgements We thank the National Institute of Nutrition and Food Safety, China Center for Disease Control and Prevention, Carolina Population Center, the University of North Carolina at Chapel Hill, the NIH (R01-HD30880, DK056350, and R01-HD38700) and the Fogarty International Center, NIH for financial support for the CHNS data collection and analysis files. We also thank the Australian Agency for International Development (AusAID) for funding Zhaohui Cui's doctoral scholarship in International Public Health at the University of Sydney, Australia. References Bibliography references: China National Bureau of Statistics (2000) China Statistic Year Book 2000. Beijing: China Statistic Press (In Chinese). CNSSCH Association (2007) Report on the 2005th National Survey on Students' Constitution and Health. Beijing: China College & University Press (In Chinese). Cole, T.J., Bellizzi, M.C., Flegal, K.M., Dietz, W.H. (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320, 1240–1243. Department of Sport Health and Art Education, Ministry of Education of China (2002) School health personnel training material. Beijing: China Fangzheng Press (In Chinese). Group of China Obesity Task Force (2004) Body mass index reference norm for screening overweight and obesity in Chinese children and adolescents. Chinese Journal of Epidemiology 25(2), 97–102(in Chinese). Ji, C.Y. & Cheng, T.O. (2008) Prevalence and geographic distribution of childhood obesity in China in 2005. International Journal of Cardiology 131, 1–8. Li, Y., Schouten, E.G., Hu, X., Cui, Z., Luan, D., & Ma, G. (2008) Obesity prevalence and time trend among youngsters in China, 1982–2002. Asia Pacific Journal of Clinical Nutrition 17, 131– 137. Ma, G.S. & Kong, L.Z. (2006) Report on 2002 China National Nutrition and Health (9): Behaviors and Lifestyles. Beijing: People’s Medical Publishing House (In Chinese). Zhai, F.Y. & Yang, X.G. (2006) Report on 2002 China National Nutrition and Health (2): Status on Diet and nutrient intake. Beijing: People’s Medical Publishing House (In Chinese).

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Secular trends in childhood obesity and associated risk factors in China from 1982 to 2006

Zhai, F.Y., He, Y.N., Ma, G.S., et al. (2005) Study on the current status and trend of food consumption among Chinese population. Chinese Journal of Epidemiology 26, 485–488 (In Chinese).

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Trends in Hong Kong and Macao and other Chinese communities

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Trends in Hong Kong and Macao and other Chinese communities Albert Lee

DOI:10.1093/acprof:oso/9780199572915.003.0010

Abstract and Keywords Obesity prevalence amongst children is rising virtually in all countries with acceleration since 1990. In the USA, obesity prevalence in children has increased from around 5% in 1963 to 1970 to 17% in 2003 to 2004. In Australia, the prevalence of overweight and obesity among children and adolescents is around 25%, so one in four adolescents seen in general practice may be overweight. Hong Kong is a leading world financial centre with an increasingly affluent lifestyle so the general pattern of mortality and morbidity among young people is similar to the United States and other developed countries. With a rapidly growing economy, there is also a worrying trend that the Chinese population elsewhere, especially in mainland China, is fast catching up with the West in terms of the prevalence of overweight and obesity. Macao, like Hong Kong, has undergone rapid economic growth over the last decade. The youth risk behavioural survey in Macao conducted in 2003 showed that the risk behaviours related to obesity, such as lack of physical activities and inadequate consumption of fruits and vegetable, had similar pattern as Hong Kong and cities in USA. Taiwan, another important Chinese community is regarded as one of the ‘Four Dragons’ of Asia (the other three are Hong Kong, Korea, and Singapore), also shows increasing trends in youth overweight and obesity. The Chinese youth population has shifted from optimal weight during the early post war period to overweight and obesity at the turn of this century. This chapter investigates the trends and risk factors associated with childhood overweight and obesity amongst the Chinese population, especially Hong Kong and Macao, with some recent data on youth risk behaviours and the health status of students. The chapter can serve as a good reference for other Asian countries undergoing similar demographic and social changes.

Keywords: overweight, obesity, children, adolescents, epidemiology, risk behaviours, Hong Kong, Macao

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Trends in Hong Kong and Macao and other Chinese communities

Chapter summary Obesity prevalence amongst children is rising virtually in all countries with acceleration since 1990 (Wang & Lobstein, 2006). In the USA, obesity prevalence in children has increased from ∼5% in 1963 to 1970 to 17% in 2003 to 2004 (Ogden et al., 2006). In Australia, the prevalence of overweight and obesity among children and adolescents is around 25%; so one in four adolescents seen in general practice may be overweight (Lobstein et al., 2004). Hong Kong is a leading world financial centre with an increasingly affluent lifestyle so the general pattern of mortality and morbidity among young people is similar to the USA and other developed countries (Lee et al., 2004). With a rapidly growing economy, there is also a worrying trend that the Chinese population elsewhere especially in mainland China, is fast catching up with the West in terms of the prevalence of overweight and obesity (Wu, 2006). Macao, like Hong Kong, has undergone rapid economic growth over the last decade. The youth risk behavioural survey in Macao conducted in 2003 showed that the risk behaviours related to obesity such as lack of physical activities and inadequate consumption of fruits and vegetable had similar pattern as Hong Kong and cities in USA (Lee, 2008). Taiwan, another important Chinese community that is regarded as one of the ‘Four Dragons’ of Asia (the other three are Hong Kong, Korea, and Singapore), also shows increasing trends in youth overweight and obesity (Chen et al., 2006). The Chinese youth population has shifted from optimal weight during the early post war period to overweight and obesity at the turn of this century. Therefore this chapter investigates the trends and risk factors associated with childhood overweight and obesity amongst the Chinese population, especially Hong Kong and Macao, with some recent data on youth risk behaviours and the health status of students. This chapter will be a good reference for other Asian countries as they are also undergoing similar demographic and social changes.

Introduction General pattern of overweight and obesity in Hong Kong In 2003, the Department of Health of the Hong Kong Special Administrative Region Government (HKSAR) conducted a telephone survey of 1700 subjects aged 20 to 64 and results revealed that 19.7% of males and 13.8% of females were found to be overweight according to self reporting and 23.4% of males and 12.7% of females were found to be obese (Kwok & Tse, 2004). During the 2003/2004 general household survey of population census, the Department of Health also investigated subjects over age 15 for weight status. The findings revealed that the prevalence of overweight and obesity were 17.8% and 21.1% respectively with a higher rate amongst the male population (DoH, 2005). The results also showed increasing prevalence with increasing age with a prevalence (p.118) of obesity over 50% amongst those aged 55 to 64. The alarming figures are sending a strong signal to take prompt action to prevent childhood obesity, as childhood obesity is generally believed to contribute to adulthood obesity (Whitaker et al., 1997). A child or adolescent with a high BMI percentile-for-age growth charts has a high risk of being overweight or obese at 35 years of age, and this risk increases with age (Guo et al., 2002). According to the data of student health services of the HKSAR Department of Health, the prevalence of obesity amongst students increased from 12.1% during the academic year 1997/1998 to 14.1% during the period 2000/2001 (DoH, 2003a, 2003b). The prevalence was found to be higher amongst primary school students.

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Trends in Hong Kong and Macao and other Chinese communities

Trends in overweight and obesity and related risk behaviours The leading causes of mortality and morbidity among youth in the USA include smoking; alcohol and other drug use; sexual behaviours that contribute to unintended pregnancy and sexually transmitted diseases (STD); dietary habits; physical inactivity; and behaviours resulting in unintentional and intentional injuries. The Center for Disease Control and Prevention (CDC) has developed the Youth Risk Behaviour Surveillance System (YRBSS) to monitor the youth health risk behaviours (Kolbe et al., 1993). The Centre for Health Education and Health Promotion of the Chinese University of Hong Kong (CUHK) started conducting a similar YRBSS in Hong Kong since 1999, adopting the measuring tools used by CDC (Lee et al., 2004; Lee et al., 2005). The questionnaire included self-reported weight and height. Findings from self reporting of weight and height have been shown to be a satisfactory assessment of overweight and obesity (Dekkens et al., 2008). Body weight is determined by energy input and output, which depend on food content and levels of physical activity. The YRBSS also contains data reflecting levels of physical activity, sedentary lifestyle (watching television), and dietary habits. Fig. 10.1 shows overweight and obesity and associated variables amongst secondary 1 to 6 students aged 12 to 18 years, in 2003 (Lee et al., 2005). Sampling of students was done by the cluster sampling method with collection of data from 3,445 students. Over 90% of students had less than the recommended five portions of fruits and vegetables per day. Over 50% of students did not participate in vigorous or moderate exercise daily with a higher proportion amongst students from higher grades. Over 10% of students were found to be overweight and 7% obese according to WHO standards of BMI by age and sex (WHO, 2007) with higher prevalence in lower form. Closer examination of the 2003 YRBSS results shows that overall 10.1% of students were overweight with a calculated BMI above the 85th percentile and below the 95th percentile (Table 10.1), and 7.53% of students were obese with a calculated BMI above the 95th percentile according to age and gender (Table 10.2). The prevalence was found to be higher amongst male students and lower forms (Tables 10.1 and 10.2). The education level of parents was not found to cause significant difference. With regard to the level of physical activities, 65 % of students participated less than 3 days per week of vigorous exercise for at least 20 minutes daily, one week preceding the survey (Table 10.3). Female students and higher-grade students participated significantly less. A higher level of parental education had lower proportions if students NOT participating for at least three times a week with statistical significance (Table 10.3). In addition, 87% of students were found to participate less than 5 days per week in moderate exercise for at least 30 minutes daily one week preceding the survey (Table 10.4). No significant difference was found between boys and girls, and upper and lower school grades. Significantly less students reported NOT participating in regular moderate exercise where parents had a higher level of education (Table 10.4). With regard to dietary habits, 95% of students consumed meals or snacks less than five times per day during the week preceding the survey (Table 10.5). No significant difference was found between male and female, upper and lower grades, and parents of different educational levels. (p.119)

Page 3 of 18

Trends in Hong Kong and Macao and other Chinese communities

(p.120)

Fig. 10.1 Risk behaviours by different grades of body weight, dietary habits & physical activity.(Overweight and Obesity were defined using the 85th and 95th BMI percentiles of the WHO standard, 2007.)

Table 10.1 At risk for overweight (BMI at or above the 85th percentile but below the 95th percentile, by age and gender) F-M Contrast

Overall

Total

Male

Female

(P-value)

Sample size

2696

1218

1478

-6.26

% (95% CI)

10.13 (±1.18)

13.41 (±1.80)

7.15 (±1.06)

(0.0000)

Sample size

1220

565

655

-6.34

% (95% CI)

12.45 (±1.88)

15.72 (±2.29)

9.38 (±1.92)

(0.0000)

Sample size

1476

653

823

-5.98

% (95% CI)

7.47 (±1.43)

10.66 (±2.76)

4.68 (±1.47)

(0.0032)

Sample size

451

176

275

-1.61

% (95% CI)

10.81 (±2.14)

11.79 (±3.35)

10.18 (±3.41)

(0.5708)

Sample size

1339

563

776

-7.36

% (95% CI)

8.95 (±2.27)

13.10 (±2.96)

5.74 (±2.20)

(0.0001)

Sample size

529

268

261

-7.97

Grade Form 1–3

Form 4–6

Parents' education Primary or below

Lower secondary

Upper secondary

Page 4 of 18

Trends in Hong Kong and Macao and other Chinese communities

F-M Contrast

% (95% CI)

Contrast (Pvalue) Grade (Form)

Parents' education

Upper secondary – Lower secondary

Lower secondary Primary

Upper secondary Primary

Upper secondary Lower secondary

Total

Male

Female

(P-value)

12.73 (±2.41)

16.20 (±3.49)

8.23 (±2.88)

(0.0038)

Total

Male

Female

-4.98

-5.06

-4.70

(0.0022)

(0.0184)

(0.0071)

−1.87

1.31

−4.44M

(0.3067)

(0.5949)

(0.0748)

1.92

4.41

-1.95

(0.3488)

(0.1081)

(0.4515)

3.78

3.10

2.49

(0.0548)

(0.2115)

(0.2854)

Overweight and Obesity were defined using the 85th and 95th BMI percentiles of the WHO standard, 2007. (p.121) Table 10.2 At risk of Obesity (BMI at or above the 95th percentile, by age and gender) F - M Contrast

Overall

Total

Male

Female

(P-value)

Sample size

2696

1218

1478

-3.35

% (95% CI)

7.53 (±1.67)

9.29 (±2.76)

5.94 (±1.41)

(0.0358)

Sample size

1220

565

655

-3.00

% (95% CI)

8.85 (±1.90)

10.40 (±2.88)

7.39 (±1.65)

(0.0618)

Sample size

1476

653

823

-3.65

% (95% CI)

6.03 (±1.86)

7.98 (±3.04)

4.33 (±1.92)

(0.0495)

Grade Form 1–3

Form 4–6

Parents' education

Page 5 of 18

Trends in Hong Kong and Macao and other Chinese communities

F - M Contrast

Primary or below

Lower secondary

Upper secondary

Total

Male

Female

(P-value)

Sample size

451

176

275

-8.18

% (95% CI)

8.68 (±3.78)

13.67 (±6.43)

5.49 (±2.96)

(0.0082)

Sample size

1339

563

776

-3.05

% (95% CI)

6.97 (±1.25)

8.69 (±3.37)

5.64 (±1.90)

(0.2253)

Sample size

529

268

261

-5.34

% (95% CI)

6.17 (±2.76)

8.50 (±4.14)

3.16 (±2.21)

(0.0271)

Total

Male

Female

-2.82

-2.41

-3.07

(0.0087)

(0.0646)

(0.0176)

-1.71

-4.98

0.16

(0.3647)

(0.1460)

(0.9316)

-2.51

-5.17

-2.32

(0.2790)

(0.1954)

(0.2435)

-0.79

-0.19

-2.48

Contrast (Pvalue) Grade (Form)

Parents' education

Upper secondary Lower secondary

Lower secondary Primary

Upper secondary Primary

Upper secondary Lower secondary

(0.5126) Overweight and Obesity were defined using the 85 standard, 2007.

(0.9305) th

and 95

th

(0.1573) BMI percentiles of the WHO

(p.122) Table 10.3 Participated in vigorous physical activity for 20 or more minutes on less than 3 of the 7 days preceding the survey F-M Contrast

Overall

Total

Male

Female

(P-value)

Sample size

3383

1663

1720

26.25

% (95% CI)

65.21 (±2.61)

52.59 (±3.47)

78.85 (±2.29)

(0.0000)

Grade

Page 6 of 18

Trends in Hong Kong and Macao and other Chinese communities

F-M Contrast

Form 1–3

Form 4–6

Total

Male

Female

(P-value)

Sample size

1728

905

823

22.87

% (95% CI)

60.41 (±3.23)

49.97 (±4.66)

72.84 (±2.82)

(0.0000)

Sample size

1655

758

897

29.63

% (95% CI)

71.99 (±2.45)

56.74 (±3.68)

86.37 (±2.51)

(0.0000)

Sample size

542

240

302

27.59

% (95% CI)

68.54 (±3.78)

53.46 (±5.19)

81.04 (±5.61)

(0.0000)

Sample size

1609

709

900

24.09

% (95% CI)

67.44 (±3.68)

54.42 (±5.70)

78.50 (±3.18)

(0.0000)

Sample size

665

365

300

26.12

% (95% CI)

61.96 (±2.67)

51.56 (±3.12)

77.68 (±6.41)

(0.0000)

Total

Male

Female

11.58

6.77

13.53

(0.0000)

(0.0243)

(0.0000)

-1.10

0.96

-2.54

(0.6391)

(0.7773)

(0.4181)

-6.57

-1.90

-3.37

(0.0203)

(0.5442)

(0.5074)

-5.48

-2.86

-0.83

Parents' education Primary or below

Lower secondary

Upper secondary

Contrast (Pvalue) Grade (Form)

Parents' education

Upper secondary Lower secondary

Lower secondary Primary

Upper secondary Primary

Upper secondary Lower secondary

(0.0354) Overweight and Obesity were defined using the 85 standard, 2007.

(0.4619) th

and 95

(p.123)

Page 7 of 18

th

(0.8109) BMI percentiles of the WHO

Trends in Hong Kong and Macao and other Chinese communities

Table 10.4 Participated in moderate physical activity for 30 or more minutes on less than 5 of the 7 days preceding the survey F-M Contrast

Overall

Total

Male

Female

(P-value)

Sample size

3383

1663

1720

2.42

% (95% CI)

86.84 (±1.53)

85.67 (±1.84)

88.09 (±2.23)

(0.1104)

Sample size

1728

905

823

2.10

% (95% CI)

84.99 (±1.51)

84.03 (±1.92)

86.13 (±2.57)

(0.2346)

Sample size

1655

758

897

2.29

% (95% CI)

89.45 (±2.31)

88.27 (±3.04)

90.56 (±2.57)

(0.1784)

Sample size

542

240

302

2.93

% (95% CI)

87.53 (±1.92)

85.93 (±3.43)

88.86 (±3.67)

(0.3545)

Sample size

1609

709

900

3.14

% (95% CI)

87.75 (±1.92)

86.05 (±2.72)

89.19 (±2.27)

(0.0904)

Sample size

665

365

300

-2.12

% (95% CI)

85.01 (±2.29)

85.85 (±2.45)

83.73 (±5.80)

(0.5632)

Total

Male

Female

4.46

4.24

4.43

(0.0021)

(0.0250)

(0.0051)

0.22

0.12

0.33

(0.8623)

(0.9460)

(0.8942)

-2.53

-0.08

-5.13

(0.1112)

(0.9701)

(0.1556)

-2.74

-0.20

-5.46

Grade Form 1–3

Form 4–6

Parents' education Primary or below

Lower secondary

Upper secondary

Contrast (Pvalue) Grade (Form)

Parents' education

Upper secondary Lower secondary

Lower secondary Primary

Upper secondary Primary

Upper secondary Lower secondary

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Trends in Hong Kong and Macao and other Chinese communities

F-M Contrast Total

Male

Female

(0.0329)

(0.9202)

(0.0358)

(P-value)

(p.124) Table 10.5 Ate fruits and vegetables less than 5 times per day (during the 7 days preceding the survey) F-M Contrast

Overall

Total

Male

Female

(P-value)

Sample size

3341

1642

1699

0.41

% (95% CI)

94.97 (±0.69)

94.78 (±0.88)

95.19 (±0.98)

(0.5214)

Sample size

1706

893

813

-0.85

% (95% CI)

94.20 (±0.94)

94.59 (±1.39)

93.74 (±1.23)

(0.3912)

Sample size

1635

749

886

1.91

% (95% CI)

96.06 (±1.23)

95.08 (±1.53)

96.99 (±1.86)

(0.1385)

Sample size

534

237

297

-0.69

% (95% CI)

95.21 (±2.31)

95.59 (±2.12)

94.90 (±3.90)

(0.7685)

Sample size

1592

702

890

-0.47

% (95% CI)

95.46 (±1.14)

95.72 (±1.72)

95.25 (±1.10)

(0.6053)

Sample size

661

362

299

1.03

% (95% CI)

93.72 (±1.78)

93.31 (±1.31)

94.34 (±2.88)

(0.3923)

Total

Male

Female

1.86

0.49

3.24

(0.0496)

(0.6960)

(0.0205)

0.25

0.13

0.35

Grade Form 1–3

Form 4–6

Parents' education Primary or below

Lower secondary

Upper secondary

Contrast (Pvalue) Grade (Form)

Parents' education

Upper secondary Lower secondary

Lower secondary Primary

Page 9 of 18

Trends in Hong Kong and Macao and other Chinese communities

F-M Contrast

Upper secondary Primary

Upper secondary Lower secondary

Total

Male

Female

(0.8303)

(0.9145)

(0.8551)

-1.49

-2.28

-0.56

(0.3820)

(0.1771)

(0.8213)

-1.74

-2.41

-0.91

(0.1890)

(0.0768)

(0.6264)

(P-value)

1999 YRBSS was conducted among 26,211 students aged 10–19 (from primary grades 4 to 6, and secondary grades 1 to 7) from a long-established school organization in Hong Kong (Lee et al., 2004). The organization manages schools of different academic levels in different geographical areas throughout the territory, so the sample population included a variety of students of different academic achievements. Profiles of the schools and the children suggested a reasonably representative sample. Around one-third of the students consumed fried food, cakes, and sweet snacks more than four times per week during the week preceding the survey with significant higher proportions amongst students of higher grades (Table 10.6). A significantly higher proportion of female students ate (p.125) cakes and sweets but a higher proportion of male students ate fried food. Students with mothers of higher level of education ate less fried food. In general, 8% and 3% of students respectively did not consume fruits and vegetables at all with a lower proportion amongst parents of higher educational level (Table 10.6). Table 10.7 compares the youth risk behaviours related to obesity of YRBSS conducted in 1999 and 2003 and also by CDC, USA, in 2003 among students from secondary forms 1 to 6. The results show that Hong Kong has a lower prevalence of students at risk of overweight and obesity compared to the USA in a 2003 survey. The prevalence of unhealthy eating habits has increased from 1999 to 2003 with nearly 100% of students eating fruits and vegetables less than five times per day and less than 3 glasses of milk or soya milk, which is a worse situation compared to the USA (Table 10.7). Risk factors associated with childhood obesity Data from the 1999 and 2003 YRBSS in Hong Kong have suggested the possible correlation of obesity-related risk behaviours with the level of education of parents, age, and sex of students. CUHK also conducted a study to investigate the eating behaviour in school children (Centre for Health Education and Health Promotion (CUHK), 2007). Children’s behaviours are much more environmentally dependent so both the school and home environments have a significant impact on childhood obesity. Home environment

Data were collected from a total of 2,988 primary 4 and 5 students and 2,569 parents participated in the pre-assessment analysis of a project titled ‘Colourful and bright fruits and

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Trends in Hong Kong and Macao and other Chinese communities

vegetables project – creating a supportive eating environment for our new generation’ in Hong Kong (Centre for Health Education and Health Promotion, 2007). The project aimed to enlighten our understanding of how the home environment would influence the eating habits of students. The pre-assessment data were used to identify factors influencing students’ knowledge and consumption of fruits and vegetables. Strong associations were found between parent’s knowledge of fruits and vegetables and their children’s consumption. Parents’ attitude towards ease of sustaining healthy eating habits was associated with children’s consumption of fruits and vegetables. The amount of fruits and vegetables consumed by parents was associated with the consumption of their children. A strong association was found between the practice of offering fruits and vegetables as a snack by patents and actual consumption by the students. Students whose peers liked eating fruits, had a higher proportion consuming adequate fruits but this phenomenon did not apply to vegetables. Multi-variate analysis by stepwise multiple logistic regression was performed to identify the predominant factors for children’s consumption of fruits and vegetables (Centre for Health Education and Health Promotion, 2007; Lee et al., 2009a; Yung et al., 2009). The findings revealed that girls were more likely to consume adequate amounts of both fruits and vegetables than their male peers. Students’ knowledge and attitudes towards fruits and vegetables, students’ consumption of fresh fruit juice, parents’ consumption and parents’ perception about their children’s diet were found to be positively associated with students’ fruit and vegetable consumption. Perceived peers’ attitude towards fruit consumption was also found to be positively correlated with students’ fruit consumption but not vegetable consumption. Regarding family background, monthly family income was found to be associated positively with students’ vegetable consumption, whereas parents’ education level was positively associated with fruit consumption. Parents’ fruit consumption was positively associated with both the fruit and vegetable consumption of their children. Parents’ influences and home circumstances have (p.126)

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Trends in Hong Kong and Macao and other Chinese communities

Table 10.6 Dietary and physical activity behaviours among adolescents in Hong Kong (1999 YRBSS. Reproduced from Lee et al. (2004), with permission from Elsevier) Sex Total

Age

Female

Male

10–14

Father education level 15–19

Mother education level

Primary or Secondary or Primary or Secondary or below above below above

Dietary Behaviour (7 days preceding the survey) Ate desserts or snacks (such as cakes, jelly, chocolates, cookies and ice-cream etc) four times or above

33.9% (8401)

34.9% (4372)

32.8% 32.2% (3924) ** (5215)

37.1% 34.1% (3186) ** (2378)

35.2% (4319) 34.0% ** (2831)

34.9% (4034)

Ate fried food four times or above

32.5% (7961)

29.0% (3594)

36.1% 30.1% (4264) ** (4821)

36.9% 33.4% (3140) ** (2303)

32.6% (3970) 33.9% (2793)

31.9% (3657) **

No consumption of fruit

8.0% (1964)

6.4% (797)

9.7% 7.8% (1148) ** (1247)

8.4% (717) **

8.9% (614) 6.6% (803) ** 8.1% (672) 6.8% (786) **

No consumption of vegetable

3.2% (779)

2.2% (277)

4.2% (493) **

2.6% (226) **

3.2% (218) 2.4% (287) ** 3.1% (252) 2.3% (267) **

Participated in vigorous physical activities

27.0% (6716)

17.7% (2292)

37.0% 29.6% (4329) ** (4813)

22.1% 24.9% (1903) ** (1745)

Participated in moderate physical activities

8.1% (2011)

6.1% (785)

10.3% 7.8% (1282) ** (1269)

8.7% (742) **

Participated in strengthening exercise

17.4% (4303)

9.9% (1282)

24.9% 15.8% (3088) ** (2548)

20.5% 16.9% (1755) ** (1177)

3.4% (553)

Physical Activities

** P〈0.05

Page 12 of 18

28.2% (3468) 24.6% ** (2058)

7.7% (533) 8.5% (1046) **

28.4% (3292)**

7.8% (644) 8.6% (993)**

18.0% (2198) 16.3% (1353)

18.2% (2094)**

Trends in Hong Kong and Macao and other Chinese communities

(p.127) Table 10.7 Estimated population prevalence rate (%) of selected risk behaviours (weighted) HK (1999)1 (16,583)

HK (2003) (3,445)

CDC (2003)

Type I Risk Behaviours At risk for overweight (at or above 85th percentile but below the 95th percentile for BMI, by age and gender) NA

10.1 (±1.2)2

15.4 (±1.3)

At risk of obesity (at or above 95th percentile for BMI, by age and gender) NA

7.5 (±1.7)

13.5 (±3.1)

Ate fruits and vegetables less than 5 times per day (during the 7 days preceding the survey) 88.2

95.0 (±0.7)

78.03 (±1.4)

Drank less than 3 glasses of milk and/or soy milk per day (during the 7 days preceding the survey) 96.9

97.7 (±0.5)

82.93 (±2.7)

Participated in vigorous physical activity for 20 or more minutes on less than 3 days of the 7 days preceding the survey 74.8

65.2 (±2.6)

37.43 (±2.3)

Participated in moderate physical activity for 30 or more minutes on less than 5 days of the 7 days preceding the survey 91.5

86.8 (±1.5)

75.33 (±1.3)

Overweight and Obesity were defined using the 85th and 95th BMI percentiles of the WHO standard, 2007. 1

Not weighted.

2

95% confidence interval.

3

Calculated from reports.

a significant impact on children’s eating behaviours. The findings of this project re-affirm the importance of parents being the target to address promotion of healthy eating and preventing childhood obesity (Brown & Ogden, 2004; Fisher et al., 2002). School environment

School environment also plays an important role in the heath behaviours of students. A study was conducted to compare health-risk behaviours of pre-vocational school (PVS) students with students of mainstream schools adjusting for the demographic factors (Lee et al., 2001). The PVS students were at higher risk for most categories of health-risk behaviours such as inadequate physical activity, insufficient consumption of fresh fruits and vegetables, unintentional and intentional injuries, smoking, alcohol drinking, glue sniffing, and early sexual

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Trends in Hong Kong and Macao and other Chinese communities

activity with multiple partners. Findings suggest that the school environment may be an influential factor in the lifestyle behaviours of students. The ‘Colourful and bright fruits and vegetables project’ aimed to guide the development of a sustainable policy and environmental change at school that would promote consumption of fruits and vegetables in primary school students (Centre for Health Education and Health Promotion, 2007). This project was based on the Health Promoting School framework, adopting an integrated approach, entailing a comprehensive needs assessment, improvement of school eating policies and eating environment, training of teachers, parents, and student ambassadors, involvement of family and community, along with a comprehensive nutrition education programme, and the active participation of students. Training, consultancy services, and professional support were also provided to the participating schools throughout the project period. Schools were encouraged to incorporate the programme into their school life. This project was successful in enhancing the nutrition knowledge; increasing fruit and vegetable consumption of the students (p.128) and their parents; reducing the consumption of high fat and high sugar snacks; improving the nutritional quality of school lunch; and empowering the teachers and parents to work collaboratively to foster a healthy eating environment and healthy culture at school. This project adds further evidence of the importance of school setting in the prevention of childhood obesity (Lee et al., 2009a).

Prevalence of overweight and obesity in Macao A recent study was conducted in Macao to study the nutritional status of Macao students (Lee et al., 2009b). It was composed of six components, including a questionnaire survey of students, parents, and schools respectively, and it also included a survey on school tuck shops and lunches, and a physical and nutritional assessment of students. A stratified random sampling method was adopted for the selection of participating schools. The study collected 4,847 student questionnaires and 3,066 parent questionnaires with response rates of 61.2% and 59.3% respectively. Physical and nutritional assessments were performed on 2,015 students aged 5 to 22. Among the 2,015 students, 1,998 students had their standing height, body weight, and waist circumference measured. Among the1,998 participating students (994 boys and 1004 girls) aged 5–22 years old, 17.2% of boys and 9.0% of girls were overweight and a further 9.2% of boys and 4.9% of girls were obese. The prevalence of overweight and obesity was highest among boys in the 9–12 age group and girls aged between 10 and 11 years. Regarding body fat distribution, 15.6% of boys and 16.9% of girls, respectively, were classified as having central obesity. Overall, 30% of students consumed more than two servings of vegetables daily (upper school students = 25.8%, junior secondary school students = 26.7%, senior secondary school students = 32.4%), and only 40% of primary school students and 15% of secondary school students were able to meet the recommendation of daily fruit intake. Less than 20% of the students followed the principles of a balanced diet and with cereals being consumed as the major portion, followed by vegetables and finally meats in the least amount. Nearly 10% of students reported that they were meat lovers and their main meals mainly consisted of a large amount of meat, followed by cereals, with vegetables being the least.

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Trends in Hong Kong and Macao and other Chinese communities

Only 5.7% of primary school students and around 4% of secondary school students reported that they had engaged in at least 60 minutes of moderate exercise every day in the week prior to the study. More than 60% of students watched television for more than 2 hours on every normal school day, and more than half of the secondary school students spent over 2 hours on other sedentary activities, such as playing video or computer games, or using computer for nonacademic purposes every day. Risk factors associated with unhealthy eating Students’ nutritional and food knowledge, eating and snacking habits, time spent on sedentary activities, and monitoring of the food supply in school were the factors affecting students’ fruit and vegetable consumption. Another factor was whether the proportion of food eaten during main meals followed the principles of a balanced diet. Family factors, including parents’ nutrition knowledge, factors considered when making food choices for their children and frequency of keeping unhealthy food at home affected the healthy eating behaviours of students.

Overview of trends in Taiwan The overall prevalence of obesity and overweight combined in boys was 19.8% in 1999 and 26.8% in 2001. It was lower in girls with 15.2% in 1999 and 16.5% in 2001 (Chen et al., 2006). The normal (p.129) weight group performed better (P〈0.05) than the overweight/obese group in all fitness tests except in the 2001 sit-and-reach test where there were no differences between the two groups. The risk of hypertension increased by nearly two times for the overweight/obese-fit group and nearly three times for the overweight/obese-unfit group compared to the normal weight-fit group. There is an increasing trend in overweight/obesity prevalence for Taiwanese youth even in a 2-year period. The overweight/obese youngsters tend to have poorer muscular strength and cardiovascular endurance than the normal weight group. The overweight/obese and unfit group had a greater risk of hypertension. However, this risk was significantly lower if obese/overweight children had a higher than average level of physical fitness and cardiovascular fitness. The 2003 YRBSS survey conducted in Taiwan, based on the same instrument used in Hong Kong, shows that 23.9% and 27.7% of secondary students were found to be at risk of overweight (BMI 〉85th percentile and 〈95th percentile by age and gender) and obesity (BMI 〉95th percentile) respectively, higher than Hong Kong and the USA. The figures correlate well with data from Chen’s study (Chen et al., 2006). The prevalence of secondary students not participating in moderate and vigorous exercise was found to be 60.6%. The proportion of secondary students eating less than five portions of fruits and vegetables was found to be 5.9%. These findings suggest that future generations in Taiwan may face the challenge of health consequences related to childhood obesity similar to their other Chinese neighbours.

Overview of trends in mainland China The prevalence and trends of overweight and obesity of boys and girls at the age of 7–18 were collected from the series of Chinese national surveillance studies on students' constitution and health (CNSSCH) between 1985 and 2000. In 2000, the prevalence of obesity and overweight in boys aged 7–18 years was 11.3% and 6.5% respectively in Beijing; 13.2% and 4.9% in Shanghai; 9.9% and 4.5% in coastal big cities; and 5.8% and 2.0% in coastal medium/small-sized cities. The prevalence of obesity and overweight in girls of the same age group was 8.2% and 3.7% in

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Trends in Hong Kong and Macao and other Chinese communities

Beijing; 7.3% and 2.6% in Shanghai; 5.9% and 2.8% in coastal big cities; and 4.8% and 1.7% in coastal medium/small-sized cities respectively (Ji & WGOC, 2007). The prevalence of obesity was low in most of the inland cities. There was a gradient distribution in groups by socioeconomic status (SES) of the study population. However, a dramatic and steady increasing trend was witnessed among all sex–age subgroups in the five urban groups, and such a trend was stronger in boys than in girls, and much stronger in children than in adolescents. Although mainland China is at an early stage in the development of childhood obesity, the prevalence of obesity in coastal big cities has reached the average level of developed countries. The increasing trend has been rapid since early 1990s, and the increments in obesity and overweight are exceptionally high. Therefore, preventive programmes should be focused on the improvement of the balance between caloric intake and energy expenditure, and interventions aimed at changing children's life styles.

Conclusions Based on various studies conducted in Hong Kong, Macao, Taiwan, and mainland China we can conclude that there is a rising trend of childhood obesity amongst Chinese children. The increasing trend appears to correlate with changing socioeconomic conditions and greater urbanization. Childhood obesity might be the price to pay for a fast-growing Chinese economy. The studies presented in this chapter from Hong Kong and Macao have shown the influence of both the home and school environments on the eating habits and physical activities of Chinese children. In view (p.130) of the potential for increasing childhood obesity, one should explore ways of creating a supportive environment at home and school for healthy eating and physical activities. The model of the Health Promoting School would be considered as a suitable model as it emphasizes the importance and efficacy of creating a supportive environment and the improvement of health literacy (Lee, 2009). References Bibliography references: Brown, R.& Ogden, J. (2004) Children’s eating attitudes and behaviour: a study of the modeling and control theories of parental influence. Health and Educational Research 19(3), 261–271. Centre for Health Education and Health Promotion, the Chinese University of Hong Kong. (2007) The Colourful and Bright Fruits and Vegetables Project: Report on Healthy Eating Behaviour in School Children. ISBN 978-988-99166-9-X. Chen, L.J., Fox, K.R., Haase, A., & Wang, J.M. (2006) Obesity, fitness and health in Taiwanese Children and adolescents. European Journal of Clinical Nutrition 60(12), 1367–1375. Dekkens, J., van Wier, M.I., Hendrikei, I.J.M., Twisk, J.W.R., & van Mechelen, W. (2008) Accuracy of self-reported body weight, height and waist circumference in a Dutch overweight working population. BMC Medical Research Methodology 8(69), doi:10.1186/1471-2288-8-69. Department of Health (2003a) Prevalence of childhood obesity in primary schools, 1997–2002. Hong Kong Department of Health.

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Department of Health (2003b) Prevalence of childhood obesity in secondary schools, 1997-2002. Hong Kong Department of Health. Department of Health (2005) Population Health Survey 2003/04 (provisional data). Hong Kong Department of Health. Fisher, J.O., Mitchell, D.C., Smiciklas-Wright, H., & Birch, L.L. (2002) Parental influences on young girls’ fruit and vegetable, micronutrient, and fat intakes. Journal of the American Dietetic Association 102(1), 58–64. Guo, S.S., Wu, W., Chumlea, W.C., & Roche, A.F. (2002) Predicting overweight and obesity in adulthood from body mass index values in childhood and adolescence. American Journal of Clinical Nutrition. 76(3), 653–658. Ji, C.Y., Working Group on Obesity in China (WGOC). (2007) Prevalence and trends of overweight and obesity in Chinese urban school-age children and adolescents, 1985–2000. Biomedical and Environmental Sciences 20(1), 1–10. Kolbe, L.J., Kann, L., & Collins, J.L. (1993) Overview of the youth risk behavior surveillance system. Public Health Report 108(Supp 1), 2–10. Kwok, P. & Tse, L.Y. (2004) Overweight and obesity in Hong Kong – What do we know? Public Health & Epidemiology Bulletin 13(4), 53–60. Lee, A., Tsang, K.K., Lee, S.H., & To, C.Y. (2001) A YRBS at Alternative High Schools and Main Stream School in Hong Kong. Journal of School Health 71(9), 443–447. Lee, A., Tsang, K.K., Healthy Schools Research Support Group (2004) Youth risk behaviour in a Chinese population: a territory wide youth risk behavioural surveillance in Hong Kong. Public Health 118(2), 88–95. Lee, A., Lee, N., Tsang, C.K.K., et al. (2005) Youth Risk Behaviour Survey, Hong Kong (2003/04). Journal of Primary Care and Health Promotion Special issue February 1–47. Lee, A. (2008) Challenge of Sustainable Development for Health Promotion. International Health Promotion Conference 2008 organised by Taiwan Health Promotion Association and ROC School Health Association, December 13–14, 2008. Lee, A. (2009) Health promoting schools: evidence for a holistic approach in promoting health and improvement of health literacy. Applied Health Economics and Health Policy 7(1), 11–17. Lee, A., Ho, M., & Keung, V. (2010) Healthy setting as an ecological model for prevention of childhood obesity. Research in Sports Medicine: An International Journal 18(1), 49–61. Lee A., Ho, M., Keung, M.W., & Wong, K.K. (2009b) Assessment of Dietary Pattern and Nutritional Status in Macao School Children. Full report in Chinese (105 pages) with summary

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report in English & Chinese, Centre for Health Education and Health Promotion, School of Public Health and Primary Care, The Chinese University of Hong Kong, October 2009. Lobstein, T., Baur, L., Uauy, R., The IASO International Obesity Taskforce. (2004) Obesity in children and young people: a crisis in public health. Obesity Reviews 5(Suppl: 1), 4–85. Ogden, C.L., Caroll, M.D., Curtin, L.R., McDowell, M.A., Tabak, C.J., & Flegal, K.M. (2006) Prevalence of overweight and obesity in the United States, 1999–2004. JAMA: the Journal of the American Medical Association 295, 1549–1555. Wang, Y. & Lobstein, T. (2006) Worldwide trends in childhood overweight and obesity. International Journal of Pediatric Obesity 1, 11–25. Wu, Y.E. (2006) Overweight and obesity in China. BMJ 333, 362–363. Whitaker, R.C., Wright, J.A., Pepe, M.S., Seidel, K.D., & Dietz, W.H. (1997) Predicting obesity in young adulthood from childhood and parental obesity. New England Journal of Medicine 337(13), 869–873. World Health Organisation. Growth Reference Data for 5–19 years (2007) Available at . [Accessed on 14 November 2008]. Yung, T., Lee, A., Ho, M., Keung, V., & Lee, J. (2010) Maternal influences on fruit and vegetable consumption of school children: case study in Hong Kong. Maternal and Child Nutrition 6(2), 190–195.

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Overweight, obesity, and associated factors among Vietnamese and Southeast Asian children and adolescents

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Overweight, obesity, and associated factors among Vietnamese and Southeast Asian children and adolescents Nguyen Hoang H. Doan Trang Tang K. Hong Michael J. Dibley

DOI:10.1093/acprof:oso/9780199572915.003.0011

Abstract and Keywords This chapter describes the prevalence and trends of overweight and obesity and associated factors among children and adolescents in Vietnam and Southeast Asia. In general there is very limited data available about child and adolescent obesity for this region. However, the results indicate a very rapid increase of overweight and obesity in school students, from pre-school to high school, especially in urban areas. In most studies, the prevalence of overweight among boys was greater than that among girls. This is a different pattern compared to child and adolescent obesity studies from industrialized countries, where the progressive increase in overweight and obesity in younger age groups was observed. Furthermore, while studies from western countries showed higher prevalence of overweight and obesity amongst children from households with low economic status, the findings from Southeast Asian countries revealed the reverse of this pattern, such as in Vietnam and Indonesia. The methods used to assess the prevalence of overweight and obesity varied among countries in this region, making cross country comparisons difficult. Studies in Southeast Asia have mentioned differences in adolescent overweight and obesity across gender and age groups, which might influence the likelihood of participating in physical activity and sport, and may differentially influence the benefits of physical activity in maintaining a healthy weight status. School location was also a notable risk factor of overweight and obesity in children in many studies of this region. Children from private schools had higher odds of overweight/obesity than those from public schools (Philippines, Indonesia); higher odds of overweight in students studying at schools in wealthy urban districts were found in Vietnam.

Keywords: overweight, obesity, children, adolescents, epidemiology, economic status, Vietnam, Asia

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Overweight, obesity, and associated factors among Vietnamese and Southeast Asian children and adolescents

Chapter summary The purpose of this chapter is to describe the prevalence and trends of overweight and obesity and associated factors among children and adolescents in Vietnam and Southeast Asia. In general there are very limited data available about child and adolescent obesity for this region. However, the results indicate a very rapid increase of overweight and obesity in school students, from pre-school to high school, especially in urban areas. The prevalence of overweight and obese adolescents in Ho Chi Minh City, Vietnam, in 2004 was 11.7% and 2.1%, respectively, whereas in the cross-sectional study in 2002, the prevalence of overweight and obese adolescents was only 5.0% and 0.6% respectively. Two separate studies, in 1990 and 1997, carried out among adolescent boys studying in the same four schools in Malaysia, reported an increase in prevalence of obesity from 1% in 1990 to 6% in 1997. In Thailand, the authors found that overweight prevalence in males increased from 12.4% in 1992 to 21.0% in 1997, whereas that of females went down from 15.2% to 12.6%. For the Philippines, there was a generally decreasing trend of overweight with age from 8 to 10 years among public schoolchildren, but not among private schoolchildren. Similar findings have been reported from Indonesia in a cross-sectional comparison between surveys in 1999 and 2004 showing a significant increase in overweight of Indonesian adolescents (from 5.3% to 8.6%) but no significant change in obesity (from 2.7% to 3.7%). In most studies, the prevalence of overweight among boys was greater than that among girls. This is a different pattern compared to studies of child and adolescent obesity from industrialized countries. In these studies, the progressive increase in overweight and obesity in younger age groups was observed. Furthermore, whereas studies from Western countries showed higher prevalence of overweight and obesity amongst children from households with low economic status, the findings from Southeast Asian countries, such as Vietnam and Indonesia, revealed the reverse of this pattern. The methods used to assess the prevalence of overweight and obesity are different from different countries of this area. Whereas the study in Vietnam used IOTF cut-offs, studies in Malaysia, Indonesia, and Philippines applied weight-for-height z-score (overweight is defined when WH Z-score 〉 2 SD) or percentile (overweight is defined when BMI ≥ 85th percentile, and obesity was defined when BMI ≥ 95th percentile), making cross country comparisons difficult. (p.133) Studies in Southeast Asia have mentioned differences in adolescent overweight and obesity across gender and age groups, which might influence the likelihood of participating in physical activity and sport and might differentially influence the benefits of physical activity on the maintenance of a healthy weight status. School location was also a notable risk factor of overweight and obesity in children in many studies of this region. Children from private schools had higher odds of overweight/obesity than those from public schools (Philippines, Indonesia) or the higher odds of overweight in students studying at schools in wealthy urban districts was found in Vietnam.

Introduction Studies of children and adolescents indicate that the prevalence of overweight and obesity is particularly high in North America, Great Britain, South-West Europe, and the Pacific countries including Australia and New Zealand (Magarey et al., 2001; Tremblay et al., 2002; Hohepa et al.,

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Overweight, obesity, and associated factors among Vietnamese and Southeast Asian children and adolescents

2004; Janssen et al., 2005). Although the prevalence of overweight and obesity in children in these countries far exceeds the levels reported for Asia, the situation, in Vietnam and other countries in Southeast Asia, is changing rapidly in response to the economic and social changes taking place in these countries (Mo-suwan & Geater, 1996; Ismail et al., 2002). Increasing levels of household wealth and urbanization are leading to a nutrition transition with children and their families having higher dietary intakes of energy and fat and lower intake of fruit and vegetables. Concurrently the levels of physical activity for children are falling with more passive forms of transportation, and reduced opportunities for active play because of crowded environments and the high expectations of parents and society for academic achievement ahead of all else. This chapter aims to answer the following research questions. How rapidly is child and adolescent obesity emerging as a public health problem in this region? What are the key factors associated overweight and obesity in children and adolescents in these countries? It addresses these research questions by reviewing recently published literature to describe the prevalence and trends of overweight and obesity and associated factors among children and adolescents in Vietnam and Southeast Asia.

Methods Literature search We searched the EMBASE®, CINAHL®, and MEDLINE® databases for published studies on child or adolescent overweight or obesity in Vietnam and other Southeast Asian countries including Thailand, Singapore, Malaysia, Indonesia, the Philippines, Laos, and Cambodia. In the search we used the queries ‘child/adolescent AND overweight/obesity’ and limited the citations to studies from the specified countries. Similar searches were conducted using BMI to replace overweight or obesity. In total we identified 26 studies that assessed the prevalence of overweight or obesity in child or adolescent populations in Southeast Asian countries. Anthropometric methods The International Obesity Task Force (IOTF) has proposed cut-off values of BMI to classify overweight and obesity in children according to age and gender (Cole et al., 2000), which have been used worldwide (Janssen et al., 2005). However, in the Southeast Asian region, different studies have applied a variety of criteria to define overweight and obesity in children. Whereas a study in Vietnam used IOTF cut-offs (Hong et al., 2007), studies in Malaysia, Indonesia, and Philippines applied weight-for-height Z-score (overweight was defined when weight-for-height Zscore 〉 2 SD) (p.134) (Tee et al., 2002; Julia et al., 2008) or percentiles (overweight was defined as BMI ≥ 85th percentile, and obesity as BMI ≥ 95th percentile) (Florentino et al., 2002; Julia et al., 2008). It was not possible to restrict the articles examined in this review to those that used IOTF criteria because of the limited number of surveys assessing overweight and obesity in children and adolescents from Southeast Asia. Thus the estimates of prevalence of overweight and obesity from different countries are based on different reference data to calculate the anthropometric indices, different cut-off values, and even different indicators (Bronner, 1996), making cross-country comparisons difficult.

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We have also included new results from two surveys the authors conducted in Ho Chi Minh City, Vietnam, in 2002 and 2004. The details of the survey methods used can be found in the original publications describing these studies (Tang et al., 2007; Hong, 2005).

Prevalence and trends in child overweight and obesity in Vietnam and Southeast Asia In Vietnam most reports of childhood and adolescent overweight and obesity are from Ho Chi Minh City, the largest and most developed city in the country. The surveys from this city indicate that recently there has been a very rapid increase in the prevalence of overweight and obesity in secondary high school students. Two recent epidemiological surveys conducted in 2002 (Tang et al., 2007) and 2004 (Hong, 2005), among representative samples from junior high school students aged from 11 to 16 years living in the city, reveal a rapid decrease in the prevalence of underweight (defined as BMI Z-score 〈 −2 SD using CDC growth reference) and a similarly rapid increase in overweight and obesity. As seen in Table 11.1, the prevalence of underweight approximately halved between 2002 and 2004, whereas the prevalence of overweight and obesity more than doubled in this population. These surveys have revealed the important differences in the prevalence of overweight and obesity by gender with boys having a higher prevalence and greater rate of increase than girls. Across the population in 2002 the prevalence of overweight and obesity in boys was 9.0% (95% CI: 5.7%, 12.3%) but only 5.9% (95% CI: 3.6%, 8.2%) in girls (Hong et al., 2007). By 2004 the prevalence of overweight and obesity in boys had more than doubled to 19.2% (95% CI: 15.7%, 22.7%), whereas for girls the rate increased to only 8.2% (95% CI: 6.6, 9.9) (Hong, 2005). In these studies a score based on an inventory of household assets was used to assess the level of household wealth and this score was divided into five equal categories with the lowest quintile representing the poorest households and the highest quintile the wealthiest households (Hong, 2005). Table 11.1 Prevalence of underweight, overweight, and obesity among Ho Chi Minh city adolescents aged 11 to 16 years BMI status

Survey 2002

Survey 2004

N = 1003

N = 2678

Percentage (%)

95% CI

Percentage (%)

95% CI

Underweight1

13.1

(10.9, 15.5)

6.6

(5.1, 8.1)

Overweight2

5.0

(3.7, 6.3)

11.7

(10.1, 13.3)

Obesity2

0.6

(0.2, 1.0)

2.1

(1.5, 2.6)

1

Defined as BMI Z-score 〈 −2 SD using CDC growth reference.

2

Defined using IOTF cut-offs.

(p.135)

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The changes in the prevalence of overweight and obesity from 2002 to 2004, broken down by gender, and the wealthiest and the poorest households, are illustrated in Fig. 11.1. This figure highlights the large differences in the prevalence of overweight and obesity by household wealth. The adolescents from the wealthiest households were significantly more overweight and obese than those from Fig. 11.1 Trends in overweight (using IOTF the poorest households. For both genders cut offs) by household wealth index and year combined in 2002 the prevalence of of survey among adolescents in Ho Chi Minh overweight and obesity in children from the City. poorest quintile of households was 4.5% (95% CI: 0.2%, 7.2%), whereas it was more than double in the wealthiest quintile of households at 11% (95% CI: 5.7%, 16.3%). This gap increased further by 2004 with the prevalence of overweight and obesity in children from the poorest quintile of households at 6% (95% CI: 3.4%, 8.5%) compared to 19.5% (95% CI: 15.3%, 23.6%) in the wealthiest quintile of households. Furthermore, the figure reveals that the rate of increase in overweight and obesity is greatest in the wealthiest adolescents especially amongst the boys. Evidence of the obesity epidemic in Ho Chi Minh City can also be found in preschool aged children. In the 2005, a cross-sectional survey of a representative sample of 670 pre-school aged children in urban areas of the city reported a remarkably high prevalence of overweight (20.5%) and obesity (16.3%) using IOTF criteria (Thi Thu Dieu et al., 2007). Boys were heavier and taller than girls in each age group. These findings confirm the cohort effect, in which progressively younger age groups in Ho Chi Minh City have more obesity, presumably because of their greater exposure to the developing obesogenic environment. The same authors have investigated the trends in overweight and obesity in pre-school children in urban areas of Ho Chi Minh City, Vietnam, from 2002 to 2005. The trends were consistent with the findings for adolescents: The prevalence of overweight and obesity almost doubled from 2002 to 2005 (21.4% and 36.8%, respectively). The proportion of boys classified as obese in 2005 (22.5%) was three times that in 2002 (6.9%). However, the increase was more evident in less wealthy districts than in wealthy districts (Dieu et al., 2009). This later finding suggests that the urban population in Ho Chi Minh City has become wealthy enough for children even from the lower socio-economic groups to experience excess weight gain. Also alarming about these findings is the extent of overweight and obesity in this young population with reported levels as high, or higher than, in most industrialized countries. In other Southeast Asian countries the information about the prevalence of overweight and obesity in children and adolescents and the changes over time is limited. Results similar to the (p.136) findings from Vietnam have been reported in a limited number of studies from other countries in Southeast Asia. Malaysia is at the crossroads of a nutrition and lifestyle transition, and Malaysians are increasingly consuming diets that are high in fat and calories and generally leading more sedentary lifestyles (Tee, 1999). In Malaysia, a study on 5995 primary school

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children in the year 1996 reported that the prevalence of overweight (weight-for-height Z score 〉 2 SD) was 7.7%. In this population, the prevalence of overweight among boys (9.5%) was about 1.9 times greater than that among girls (5.1%) (Tee et al., 2002). Two separate studies, in 1990 and 1997, carried out among adolescent boys studying in the same four schools in Klang Valley, reported an increase in prevalence of obesity from 1% in 1990 to 6% in 1997 (Ismail & Vickneswary, 1999; Ismail & Zulkifli, 1996). A review of research on overweight and obesity in Thailand also reported a trend to increasing overweight and obesity in Thai children. In a longitudinal study, 2252 primary and secondary schoolchildren of Hat Yai, a municipality in southern Thailand, were recruited in 1992 and after a follow-up for 5 years, the authors found that prevalence of overweight in males (using the 85th percentile of the US First National Health and Nutritional Examination Survey reference for age and sex as a cut-off point) increased from 12.4% in 1992 to 21% in 1997, whereas that of females went down from 15.2% to 12.6%. At the end of the fifth year, 11.8% of the children remained overweight whereas 4.5% had become overweight (Mo-suwan et al., 2000). Data from the national health survey in 1997 and 2001 revealed a substantial rise in prevalence of obesity from 5.8% in 1997 to 7.9% in 2001 for 2–5-year-olds (Mo-suwan, 2008) from 5.8% in 1997 to 6.7% in 2001 for the 6–12-year-olds. The prevalence was higher in the urban children (Mosuwan, 2006). Using the same adiposity indices, overweight and obesity in urban school-aged children increased from 15.1% in 2001 (Mo-suwan, 2006) to 16.7% in 2005 (Mo-suwan, 2008). A study in 2003 amongst the primary school children (7-9 years old) in Northeast Thailand (urban Khon Kaen) showed the prevalence of childhood obesity to be 10.8%, whereas in Pattani province a survey in 2004 on 9393 public high school students (13–18 years old) revealed 9% overweight/obesity (6.8% overweight/2.2% obesity). In Singapore, Ho indicated that there was a steady increase of prevalence from 1976 to 1980, with a sharp increase in prevalence in 1983. It was found that obesity was significantly more prevalent in males than in females (Ho, 1985). For the Philippines, the prevalence of overweight among private schoolchildren (24.9%) was almost four times higher than that among public schoolchildren (5.8%): there was a generally decreasing trend of overweight with age from 8 to 10 years among public schoolchildren, but not among private schoolchildren (Florentino et al., 2002). Similarly, in Indonesia, in a study of urban schoolchildren aged 8 to 10 years in Bogor and Jakarta, there were more overweight children in the private schools than in the public schools. The prevalence of overweight (BMI 〉 85th percentile) ranged from 15.3% (girls) to 17.8% (boys) (Soekirman et al., 2002). In another study, the cross-sectional comparison between the 1999 and 2004 surveys showed a significant increase in overweight of Indonesian adolescents (from 5.3% to 8.6%) but no significant increase in obesity (from 2.7% to 3.7%) (Julia et al., 2008). After 5.1 (± 0.6) years, the prevalence of overweight and obesity increased from 4.2% and 1.9% in childhood to 8.8% and 3.2%. A cross-sectional study conducted in school-aged pre-pubertal children in two adjacent areas in Central Java (Yogyakarta as an urban area, and Gunung Kidul as a rural area) reported a prevalence of overweight of 2.3%. In the study both rural and poor urban children were significantly less likely to be overweight than were non-poor urban children (Julia et al., 2004).

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The findings from many studies of child and adolescent overweight/obesity in Southeast Asia show strikingly different patterns of overweight and obesity compared to studies of child and (p.137) adolescent obesity from industrialized countries. Firstly, most studies from Western countries have found a higher prevalence of obesity with girls than with boys, the reverse of what is reported in Southeast Asia. A comparison of studies among 13 European countries and the US reported that the prevalence of overweight (BMI ≥ 95th percentile) was highest in the US with higher rates in girls than in boys (Lissau et al., 2004). A cross-sectional study in England also found more girls than boys were overweight (Saxena et al., 2004). The studies in Ho Chi Minh City found that overweight and obesity was more prevalent in males than in females (Hong, 2005; Thi Thu Dieu et al., 2007). These gender differences could be explained in terms of a societal male gender preference or different social expectations about body size and proportions between girls and boys in Asian countries. Reports from Malaysia reveal an increasing prevalence of obesity in adolescents, especially males from urban areas who were more obese than females (Noor, 2002). In Indonesia, the obesity rate was also found to be higher in boys than in girls (Collins et al., 2008; Julia et al., 2008; Soekirman et al., 2002). Secondly, the progressive increase in overweight and obesity in younger age groups has not been reported in developed countries, although a similar pattern has been reported in other countries undergoing a rapid nutrition transition (Li et al., 2005; Mo-suwan et al., 1993). In studies from Vietnam, BMI was also related to age (Tang et al., 2007). In Malaysia, the prevalence of overweight decreased with increasing age (Tee et al., 2002). In Vietnam the distribution of age and gender across categories of wealth, pubertal stage, school location, and residence were examined showing that these variables were distributed equally across wealth, pubertal stage, school location, and residence categories (Hong, 2005). Thirdly, most studies from Western countries have reported higher prevalence of overweight and obesity amongst children from households with low economic status. A cross-sectional study from eastern France conducted in 2001 found the prevalence of overweight and obesity was higher in low economic zones and was inversely associated with family income tax (a measure of income), for example, in boys 23.6% from the lowest-income group compared to 15.3% from the highest-income group (Klein-Platat et al., 2003). Similar findings have been reported for adolescents in the US from the Third National Health and Nutrition Examination Survey (NHANES) 1988–1994, where the prevalence of overweight and obesity (defined as BMI 〉 85th percentile of CDC 2000 Growth Reference) was 32.7% in low-income families and 19.0% in highincome families (Wang, 2001). In Vietnam, the authors found increased odds of childhood overweight/obesity in wealthier households (Hong, 2005; Thi Thu Dieu et al., 2007), similar to that reported in other developing countries undergoing a nutrition transition such as Indonesia (Julia et al., 2004). However many studies from other Southeast Asian countries have not examined this phenomenon. Overall, these findings highlight that the patterns of overweight and obesity found in Southeast Asia are very different from those in industrialized countries and indicate that interventions developed in the West may not be suitable for Southeast Asian countries.

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Factors associated with childhood overweight and obesity in Southeast Asia Weight gain is the result of a positive energy balance (consuming more energy than is expended). Energy expenditure, as assessed through levels of physical activity, declines in children as they reach adolescence, particularly in adolescent girls. Many studies have mentioned differences in adolescent overweight and obesity across gender and age groups (i.e. there was an increased risk of overweight and obesity in male adolescents and age had a positive association with BMI) (Collins et al., 2008; De Onis et al., 2001; Jackson et al., 2002; Li et al., 2008; Tang et al., 2007). (p.138) Both studies conducted in pre-school aged children and adolescents in Ho Chi Minh City, Vietnam, found higher odds of being obese in boys than in girls (Hong, 2005; Thi Thu Dieu et al., 2007). Furthermore, the prevalence of overweight/obesity was significantly higher in the younger age groups (Tang et al., 2007). Gender and age might influence the likelihood of participating in physical activity and sports, and might differentially influence the benefits of physical activity on the maintenance of a healthy weight status (Davison & Birch, 2001). Boys are usually more physically active than girls (Sallis et al., 2000); however, adolescent girls tend to be more self-aware of their appearance and more likely to be concerned about their weight than boys. The dietary practices of younger children are much more dependent on parental control, and parents are more likely to encourage their younger children to eat more. This encouragement has been observed as a factor positively associated with children’s energy intake and also associated with the time children spend eating, which in turn, is positively associated with their degree of fatness. In studies from Malaysia, Indonesia, and Vietnam, the obesity rate was also found to be higher in boys than in girls (Collins et al., 2008; Julia et al., 2008; Tang et al., 2007; Hong, 2005; Tee et al., 2002; Thi Thu Dieu et al., 2007). However, this gender difference was not evident in Philippine children (Florentino et al., 2002), and the reverse was found in Thailand (Aekplakorn & Mo-suwan, 2009; Mo-suwan et al., 2000). Among countries in Southeast Asia, the prevalence of childhood overweight and obesity has increased concomitantly with the extent of the country’s socioeconomic transition. The prevalence is generally higher in urban areas than in the rural areas, and in higher socioeconomic groups of the population. Unlike developed countries, where the highest prevalence of overweight has usually been found among poorer families, in studies of Southeast Asia, we found an increased risk of childhood overweight/obesity in wealthier households, similar to that reported in other developing countries undergoing a nutrition transition (Collins et al., 2008; Florentino et al., 2002; Julia et al., 2008; Mo-suwan & Geater, 1996; Tee et al., 2002; Tang et al., 2007; Thi Thu Dieu et al., 2007). Even in Indonesia, the growth of high socioeconomic class preschool children from Jakarta was at least equal to that of the American reference population (Droomers et al., 1995). School location was a notable risk factor of overweight and obesity in children in many studies of this region. In Vietnam, most of the schools with a high academic standard are located in the wealthy urban districts, and as a result these schools tend to attract students from higher socioeconomic families (Hong, 2005). Hence the higher risk of overweight in students studying at schools in wealthy urban districts is expected. In some schools because academic achievement is the main focus of the curriculum the requirement for physical activity has

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declined. In addition, the play yards for students in schools located in wealthy urban districts were significantly narrower that those in schools located in less wealthy urban districts. Similar findings have been reported from studies in the Philippines and Indonesia, where children from private schools had higher odds of overweight/obesity than those from public schools (Florentino et al., 2002; Soekirman et al., 2002). In contrast to findings from developed countries, where the prevalence of overweight was inversely associated with family income, results from studies of the Southeast Asian region found an increased risk of overweight/obesity in adolescents from families of higher economic status. Parents from wealthier households with adequate resources for food, televisions (TVs), computers and other ‘labour saving’ household devices are likely to have encouraged diets and lifestyles for their children that promote obesity. Higher rates of overweight were found in schools located in wealthy urban districts (Hong, 2005). The most desirable schools in Ho Chi Minh City are located in these districts and there is intense competition to gain admission. Children from higher socioeconomic status families and children whose parents have higher levels of education are more likely to gain admission to these schools. Furthermore, schools in wealthy districts usually have less space for playgrounds and may place less emphasis on physical activity in the curriculum. (p.139) The findings from the Southeast Asia region showed a markedly higher prevalence of overweight and obesity in children from urban areas when compared to rural areas (Hong, 2005; Julia et al., 2004; Tee et al., 2002), in contrast to studies from the West where the urban–rural differences in overweight and obesity in children are much smaller and the prevalence of overweight and obesity is higher in the rural than in the urban areas (Moreno et al., 2001; Oner et al., 2004). In contrast to the situation in developed countries, most countries in Southeast Asia face a double burden of both under-nutrition and over-nutrition, with both problems exerting considerable stress on the health system. Parental characteristics were explored in the present study, including the parent’s education, and family economic status. In contrast to findings from French and US studies (Gordon-Larsen et al., 2003; Klein-Platat et al., 2003), where the percentage of overweight and obese children was higher if their parents (both or either father or mother) were of lower level of education, the two cross-sectional studies in Ho Chi Minh City revealed the reverse pattern where the percentage of overweight and obese children was higher if their parents had higher levels of education (Hong, 2005; Thi Thu Dieu et al., 2007). This is understandable in the context of Vietnam where recent periods of economic difficulties and insufficiency of food lead parents to perceive fat children as healthy and well nourished. Well-educated adults have found it easy to find jobs as the economic reforms began in the mid-1980s and they can easily provide their children with a comfortable life including dietary and physical activity lifestyles that place the children in these families at higher risk of overweight. In developed countries, this phenomenon might be explained by attitudes about dietary recommendations and the value of slimness may be linked more to educational level rather than income level. However, in developing countries highly educated parents might have good jobs and want to provide their children with a ‘modern’ life with plenty of modern recreational facilities such as TVs and computers. The parents often give pocket money to their children, which may be used to buy snacks. For these

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reasons, overweight and obesity is more common in wealthier families and in children with more highly educated parents. The parents’ perception of well-being and healthiness may also help to explain the relationship between parent’s overweight status with overweight and obesity in children. Some studies have noted that mothers with higher weight status are more likely to give their children snacks of low nutrient density (Davison & Birch, 2001) and children of overweight mothers are also more likely to consume more fat as a proportion of food intake in comparison to children of normal weight mothers (Nguyen et al., 1996). A genetic familial tendency to overweight and obesity may also contribute to the association between overweight parents and overweight children. Studies in Vietnam found a higher risk of being overweight when the parents were overweight (Hong, 2005; Thi Thu Dieu et al., 2007). Mothers are usually more involved with child care related to growth, e.g. in food preparation and choice. In these studies, children and adolescents with overweight mothers had nearly 1.5–4 times higher odds of overweight and obesity compared to those with normal weight mothers. The odds of overweight in children whose father was overweight also increased 1.59–3 times. However, the risk was highest for children when both parents were overweight. These findings also found in Thailand (Mo-suwan & Geater, 1996). As mentioned earlier, the reason for overweight and obesity in children and adolescents involves a complex set of factors and multiple contexts that interact with each other (Davison & Birch, 2001). Family environments are likely to influence the risk the child would become overweight. The results of studies in Southeast Asia revealed a negative association between availability of fruit at home with the odds of overweight and obesity. Children’s eating habits are influenced by their family or parents’ dietary practices (Gibson et al., 1998). Increasing their food availability and larger portion sizes promotes overeating (Hill & Peters, 1998). In Asia, it is common for the mother to be the one who is mainly responsible for food preparation at home; hence the mother’s (p.140) nutritional knowledge and concern for disease prevention will be strongly associated with the children’s food consumption. Thus, if fruits were usually stored in the fridge at home children would be more likely to eat them rather than consuming other low nutrient foods. The findings from studies of this region, once again, confirm the role of the home environment in the development of childhood obesity. Many studies (Giammattei et al., 2003; Janssen et al., 2004) have reported a positive association of obesity with soft drink consumption. Giammattei even reported that ‘drinking three or more soft drinks per day was associated with a 46% increase in chance of being overweight’. (Giammattei et al., 2003). In the study of Vietnamese adolescents, frequent consumption of soft drinks increased the odds of overweight more than two times if compared to not consuming these beverages. Infrequent consumption of soft drinks still increased the odds of overweight and obesity by approximately 1.5 times. These findings contrast with the results for frequency of consumption of fruit and vegetables, where high frequency of consumption of vegetables halved the odds of overweight and obesity compared to low or no consumption of vegetables, and similarly high frequency of consumption of fruit reduced the odds of overweight and obesity by one-fifth. This impact was higher when children frequently consumed both (fruits and vegetables). These findings imply that the role of diet in overweight and obesity in adolescents is complex and needs further study.

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The amount of leisure time, especially time spent watching TV, playing computer games and videogames has been considered as a key factor for overweight. In the study on Vietnamese adolescents time watching TV during the week had a strong association with overweight/obesity in adolescents: children who spent 4 hours or longer per week day watching TV were four times more likely to be overweight than those who spent only 1 hour or less per day watching TV. The odds were also higher with those who spent 2 to 3 hours per week day watching TV. Several researchers have noted that watching TV can decrease the amount of time spent performing physical activity and can also be associated with increased food consumption either during viewing or as a result of food advertisements. However, in a study of children from Yogyakarta (Collins et al., 2008), time spent on the computer, watching TV, or on play station, and snacking while watching TV or frequency of fast food consumption were not found to be significantly independently related to obesity in the multivariate analysis. Similar findings were found in Malaysian female adolescents (Wan et al., 2004). The level of physical activity as measured by energy expenditure of the urban adolescents in Vietnam was the same as that reported for normal weight female adolescents in Malaysia (Wan et al., 2004). The length of time the adolescents in Ho Chi Minh City spent watching television and playing with computer or video games was lower on average than what was reported in Malaysia. This may be because Ho Chi Minh City adolescents spend much more time after class studying (approximately 135 minutes per day) (Hong, 2005). This finding highlights the level of the schoolwork burden of high school students in Vietnam and this sedentary behaviour is likely to be an important contributor to overweight and obesity in this population.

Conclusions Many Southeast Asian countries currently confront a nutrition transition with the double burden of underweight and overweight in adolescents. The problem of overweight and obesity is greater in males than in females, in younger age groups, in wealthy urban districts, and in children from high economic status families. Appropriate public health policies are needed to deal with both problems and long-term follow-up of these subjects should be undertaken to have a better understanding of the factors associated with obesity and the potential for prevention for overweight and obesity in this population of adolescents. References Bibliography references: Aekplakorn, W. & Mo-suwan, L. (2009) Prevalence of obesity in Thailand. Obesity Reviews 10, 589–592. Bronner, Y.L. (1996) Nutritional status outcomes for children: ethnic, cultural, and environmental contexts. Journal of American Dietitics Association 96, 891–903. Cole, T.J., Bellizzi, M.C., & Flegal, K.M. (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320, 1240–1243. Collins, A.E., Pakiz, B., & Rock, C.L. (2008) Factors associated with obesity in Indonesian adolescents. International Journal of Pediatric Obesity 3, 58–64.

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Davison, K.K. & Birch, L.L. (2001) Childhood overweight: a contextual model and recommendations for future research. Obesity Reviews 2, 159–171. De Onis, M., Dasgupta, P., Saha, S., Sengupta, D., & Blossner, M. (2001) The National Center for Health Statistics reference and the growth of Indian adolescent boys. American Journal of Clinical Nutrition 74, 248–253. Dieu, H.T., Dibley, M.J., Sibbritt, D.W., & Hanh, T.T. (2009) Trends in overweight and obesity in pre-school children in urban areas of Ho Chi Minh City, Vietnam, from 2002 to 2005. Public Health Nutrition 12, 702–709. Droomers, M., Gross, R., Schultink, W., & Sastroamidjojo, S. (1995) High socioeconomic class preschool children from Jakarta, Indonesia are taller and heavier than NCHS reference population. European Journal of Clinical Nutrition 49, 740–744. Florentino, R.F., Villavieja, G.M., & Lana, R.D. (2002) Regional study of nutritional status of urban primary schoolchildren. 1. Manila, Philippines. Food and Nutrition Bulletin 23, 24–30. Giammattei, J., Blix, G., Marshak, H.H., Wollitzer, A.O., & Pettitt, D.J. (2003) Television watching and soft drink consumption: associations with obesity in 11- to 13-year-old schoolchildren. Archives of Pediatrics and Adolescent Medicine 157, 882–886. Gibson, E.L., Wardle, J., & Watts, C.J. (1998) Fruit and vegetable consumption, nutritional knowledge and beliefs in mothers and children. Appetite 31, 205–228. Gordon-Larsen, P., Adair, L.S., & Popkin, B.M. (2003) The relationship of ethnicity, socioeconomic factors, and overweight in US adolescents. Obesity Research 11, 121–129. Hill, J.O. & Peters, J.C. (1998) Environmental contributions to the obesity epidemic. Science 280, 1371–1374. Ho, T.F. (1985) Eleventh Haridas memorial lecture. Childhood obesity in Singapore primary school children: epidemiological review and anthropometric evaluation. Journal of Singapore Paediatric Society 27(Suppl 1), 5–40. Hohepa, M., Schofield, G., & Kolt, G. (2004) Adolescent obesity and physical inactivity. New Zealand Medical Journal 117, U1210. Hong, K.T. (2005) Diet, physical activity, environments and their relationship to the emergence of adolescent overweight and obesity in Ho Chi Minh City, Vietnam. University of Newcastle: Faculty of Health. Hong, T.K., Dibley, M.J., Sibbritt, D., Binh, P.N., Trang, N.H., & Hanh, T.T. (2007) Overweight and obesity are rapidly emerging among adolescents in Ho Chi Minh City, Vietnam, 2002–2004. International Journal of Pediatric Obesity 2, 194–201.

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03 Wolney Lisboa Conde Carlos Augusto Monteiro

DOI:10.1093/acprof:oso/9780199572915.003.0012

Abstract and Keywords This chapter describes the prevalence, distribution, and changing trends of overweight and obesity among Brazilian adolescents across the last three decades, including the most recent population study from 2002 to 2003. Increases in height, weight, and BMI were observed in both genders and across all time periods and income groups. Among males, the prevalence of overweight and obesity increased consistently during all three time periods and among all income groups. Among females, overweight and obesity increased in the early studies, but tended to decrease in more recent years and this trend was particularly marked in the higher income groups. The chapter suggests that improved nutrition and infant health in conjunction with better social and educational conditions may have influenced the increase in height, weight, and overweight among Brazilian children and adolescents over the past few decades. The recent decrease in overweight and obesity among young females may be explained by the social pressure for a slim body. Further studies should investigate these trends and should particularly focus on explaining the socioeconomic factors which appear to impact on childhood obesity.

Keywords: overweight, obesity, children, adolescents, epidemiology, BMI, Brazil

Chapter summary In this chapter we describe the prevalence, distribution, and changing trends of overweight and obesity among Brazilian adolescents across the last three decades, including the most recent population study from 2002 to 2003. Increases in height, weight, and BMI were observed in both genders and across all time periods and income groups. Among males, the prevalence of

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

overweight and obesity increased consistently during all three time periods and among all income groups. Among females, overweight and obesity increased in the early studies, but tended to decrease in more recent years and this trend was particularly marked in the higher income groups. We suggest that improved nutrition and infant health in conjunction with better social and educational conditions may have influenced the increase in height, weight, and overweight among Brazilian children and adolescents over the past few decades. The recent decrease in overweight and obesity among young females may be explained by the social pressure for a slim body. Further studies should investigate these trends and should particularly focus on explaining the socioeconomic factors, which appear to impact on childhood obesity.

Introduction Adolescents who present with excessive weight to height ratio may be more exposed to several adverse consequences in adulthood, including social, psychological, and physical health aspects. The impacts of obesity on child or adolescent health may include earlier sexual maturation, accelerated growth, advanced bone ages, hyperlipidemia, and glucose intolerance (Dietz, 1998; Freedman et al., 1999). Adolescents from Spain, Canada, Australia, Crete, New Zealand, and Germany, for example, have shown an increase in overweight and obesity of 1 percentage point or more per year from the 1980s through to the 1990s (Wang & Lobstein, 2006). In Latin America, adolescents from Chile and two regions of Brazil show an increase of overweight and obesity of 0.5 percentage point or more per year at the same period (Wang & Lobstein, 2006) and in Mexico, adolescent overweight and obesity reached 24.7% in males and 27.5% in females (del Río-Navarro et al., 2004). A recent review including countries from the western hemisphere and using 1990s and 2000s data show that in Caribbean, South American, and Central American regions, overweight and obesity reached one in three male and one in four female adults (Ford & Mokdad, 2008). In Brazil, from 1974/75 to 1996/97 there was an overall increase in mean BMI and prevalence of overweight and obesity among adolescents from the two most populated Brazilian regions (p. 145) (da Veiga et al., 2004; Monteiro et al., 2002;). A further analysis by gender and income pointed to a slight decline of overweight among older girls belonging to higher income families (da Veiga et al., 2004). As far as we know, there is no study describing a large representative sample of secular trends in overweight and obesity among the Brazilian adolescent population. In this chapter we describe the prevalence, distribution, and changing trends of excess weight among Brazilian adolescents across the last three decades, including the 2000s.

Subjects and methods The data are representative of the 10- to 19-year age range in Brazil and come from three national surveys: Estudo Nacional de Despesa Familiar (ENDEF-1974/75) with 64,047 individuals (boys = 31,296; girls = 32,751), Pesquisa Nacional Saúde e Nutrição (PNSN-1989) with 13,711 individuals (boys = 6,926; girls = 6,785), and Pesquisa de Orçamentos Familiares (POF-2002/3) with 35,487 individuals (boys = 18,378; girls = 17,109). The three surveys were planned using complex household samples and are representative of the Brazilian population. The first two surveys did not sample the scarcely populated rural census sectors in the northern region of Brazil, thus we excluded these sectors from the third study. The three surveys were

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

carried out by the IBGE (acronym in Portuguese for Brazilian Institute of Geography and Statistics). Socioeconomic position was described by fifth of per capita income, where the first quintile contains the poorest and the fifth quintile contains the richest. The data from the three surveys were pooled to perform all analyses. Overweight was classified according to the International Obesity Task Force criteria (Cole et al., 2000) as the BMI values equal to or greater than the adult equivalent 25 kg/m2 critical values. The changes in overweight and obesity prevalence over time were fitted using a Poisson regression having the overweight and obese status as the outcome, and age, survey-specific income quintiles, survey year, and an interaction term between income and survey year as explanatory variables. To test homogeneity of time changes across income groups we used the X 2

of Mantel–Haenszel (Szklo & Nieto, 2007).

Results Crude estimates, in Table 12.1, show a continuous increase in height and BMI for both sexes in almost all age groups across the three surveys. In 1974/75 the female prevalence of overweight and obesity was 2.5 times that observed among males; in 1989 the rate was 2.1 times and in 2002/03 the ratio dropped to 0.95. In the female age groups, we note that systematic increases over two periods occurred only in adolescents under 14 years of age and that among those aged from 14 to 15 years the prevalence is virtually flat in the most recent time period observed. From 16 years and older, females show a consistent decrease in mean BMI and overweight/ obesity prevalence from 1989 to 2002/03. By dividing the latter with the former frequency values and raising the result to inverse of time span, one estimates an annual changing rate for overweight/obesity throughout the three surveys. The rate of increase in overweight/obesity for males was 5.7% per year from 1974/75 to 1989 and 8.5% per year from 1989 to 2002/03. For females, the rate of increase in overweight/ obesity was 4.8% per year in 1974/75 to 1989 and 0.4% per year from 1989 to 2002/03. The rate of increase in height for male was 0.16% per year from 1974/75 to 1989 and 0.23% per year from 1989 to 2002/03. For females, during the same time frame, the rate of increase for height was 0.10% per year and 0.19% per year, respectively. Table 12.2 presents height changes by time period for socioeconomic position. (p.146)

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

Table 12.1 Anthropometric indicators in three national surveys of adolescents aged 10 to 19 years in Brazil in 1974/75, 1989, and 2002/03 BMI (kg/m2) Age (year)

Height (cm)

Overweight/Obese (%)

1974/75

1989

2002/03

1974/75

1989

2002/03

1974/75

1989

2002/03

10–11

16.1

16.7

17.7

134.4

137.8

141.5

2.7

6.0

18.0

12–13

16.8

17.8

18.6

144.2

148.8

153.7

1.8

6.0

14.4

14–15

18.2

19.1

19.7

156.2

159.7

164.5

2.4

5.3

10.9

16–17

19.6

20.3

20.9

164.5

167.6

170.3

2.4

4.4

10.1

18–19

20.6

21.2

21.9

167.4

169.6

171.7

2.9

6.5

13.0

10–19

18.1

18.8

19.8

151.8

155.4

160.4

2.4

5.7

13.2

10–11

16.3

17.1

17.6

135.7

139.4

143.0

3.6

9.4

14.4

12–13

17.9

18.9

19.1

146.9

150.2

153.7

4.6

9.7

12.9

14–15

19.8

20.6

20.3

153.7

155.8

159.1

7.2

11.5

12.2

16–17

20.8

21.6

20.9

155.7

156.6

160.4

7.6

14.0

10.4

18–19

21.1

22.1

21.4

156.2

157.4

160.9

7.9

15.5

12.0

10–19

19.0

19.8

19.8

149.0

151.1

155.0

6.0

11.8

12.5

Male

Female

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

The increase in height was greater in the second time period relative to the first time period in all income quintiles for females. Among males, the increase in height was greatest among the fourth income quintile. The increase in height was most evident among older female adolescents from 1989 to 2002/03.

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

Table 12.2 Age-standardized mean height (cm) among adolescents aged 10 to 19 years by quintiles of per capita income and age group in Brazil in 1974/75, 1989, and 2002/03 Income

10–14 y

15–19 y

10–19 y

Fifth

1974/75

1989

2002/03

1974/75

1989

2002/03

1974/75

1989

2002/03

1

138.5

143.0

148.5

157.8

161.5

165.4

147.8

151.8

156.4

2

141.5

146.9

150.3

160.6

164.4

167.7

150.6

155.0

158.2

3

144.5

148.9

153.0

163.1

165.4

169.3

153.2

156.6

160.4

4

147.3

149.8

155.4

165.5

168.7

170.8

155.8

158.7

162.3

5

151.2

154.1

157.0

168.4

170.6

172.6

159.2

161.6

164.0

1

140.4

144.4

148.5

152.3

155.0

157.4

145.7

148.8

152.4

2

143.4

147.0

150.4

153.6

155.1

158.9

147.8

150.5

154.0

3

145.8

149.4

152.1

155.7

156.3

160.1

150.0

152.4

155.4

4

147.5

149.8

153.4

156.5

158.2

161.1

151.3

153.4

156.6

5

150.3

151.7

154.4

157.8

159.7

162.7

153.4

155.0

157.8

Male

Female

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

(p.147) The increase in overweight and obesity was greatest among those aged 10 to 13 years for both sexes in the two time periods. There was an important difference between males and females from 1989 to 2002/03 with overweight/obesity increases for females being 50% or less than that for males at any age group. Overall, male adolescents from the higher quintiles of the income distribution were approximately three times more likely to be overweight or obese than those in the lower quintiles. In females, those from the higher quintiles of income were two times more likely to be overweight or obese than those from the lower-income quintiles (Table 12.3). Among males, the annual changing rate for overweight was greater from 1989 to 2002/03 relative to the earlier period in almost all age groups. Among females the opposite occurred, with a lower rate of annual change among all age groups in 1989 to 2002/03 relative to the earlier time period. By separating adolescents into younger (10 to 14 years) and older (15 to 19 years) groups, we observe similar trajectories for males but not for females. Males and females aged 10 to 14 year had more overweight and obesity as their family income increased. In the older age groups, male and female adolescents had different trajectories for BMI and overweight (Table 12.1) and different relationships between overweight/obesity and socioeconomic position (Table 12.4), particularly from 1989 to 2002/03 time span. When observing the differences within time changes among older adolescents, one can see that the relative risk (RR) of overweight/obesity in males increased over time, but with no particular linear trend with income strata (Table 12.4). For older adolescent females, however, the opposite trend is observed when observing the RR from the first to the second time periods. From 1974/75 to 1989, the RR increased among young female in all income quintiles but from 1989 to 2002/03, the RR dropped significantly except for the lowest income group. The change in overweight and obesity over the three time periods observed was interesting and valuable from a research point of view. A remarkable trend was observed in the most recent survey conducted in 2002/03, when the rates of overweight and obesity in relation to income

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

Table 12.3 Prevalence of overweight and obesity (%) among adolescents aged 10 to 19 years by quintiles of per capita income and age group in Brazil in 1974/75, 1989, and 2002/03 Income

10–14 y

15–19 y

10–19 y

Fifth

1974/75

1989

2002/03

1974/75

1989

2002/03

1974/75

1989

2002/03

1

0.9

2.1

6.5

0.8

2.7

5.7

0.8

2.4

6.2

2

1.0

2.6

12.8

1.3

3.1

7.2

1.1

2.8

9.8

3

1.7

5.6

15.8

2.6

4.4

10.9

2.2

5.0

13.2

4

2.2

4.8

20.1

2.6

7.1

15.5

2.4

5.9

17.6

5

6.6

17.2

22.9

4.9

8.0

15.7

5.7

12.5

19.2

1

2.1

6.4

7.5

6.4

7.4

9.0

4.2

6.9

8.5

2

2.8

7.3

14.1

6.4

13.6

9.9

4.6

10.4

12.0

3

4.1

10.3

12.9

8.7

15.5

13.8

6.4

12.8

13.3

4

4.9

13.6

14.4

8.6

14.8

12.9

6.7

14.2

13.7

5

9.0

17.7

18.2

9.0

14.1

11.3

9.0

15.9

14.9

Male

Female

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

(p.148)

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

Table 12.4 Relative risk (RR) for time changes in the age-adjusted prevalence of overweight and obesity among Brazilian adolescents by quintiles of per capita income and age group. Brazil: 1974/75 to 2002/03 Income

RR for 1989 versus 1974/75

RR for 2002/03 versus 1989

Quintile

10–14 y

15–19 y

10–19 y

10–14 y

15–19 y

10–19 y

1

2.33 (1.35–4.02)

3.39 (1.56–7.39)

2.65 (1.70–4.14)

3.05 (2.24–4.16)

2.31 (1.58–3.37)

2.72 (2.14–3.46)

2

2.51 (1.49–4.23)

2.43 (1.40–4.23)

2.48 (1.70–3.61)

4.74 (3.59–6.26)

2.28 (1.66–3.11)

3.44 (2.80–4.24)

3

3.24 (2.15–4.89)

1.74 (1.19–2.54)

2.38 (1.80–3.13)

2.77 (2.26–3.40)

2.44 (1.91–3.10)

2.58 (2.21–3.02)

4

2.03 (1.36–3.02)

2.80 (1.98–3.95)

2.48 (1.91–3.22)

4.36 (3.48–5.47)

2.15 (1.80–2.56)

2.92 (2.54–3.35)

5

2.56 (2.05–3.21)

1.69 (1.29–2.22)

2.18 (1.84–2.60)

1.34 (1.18–1.52)

1.91 (1.61–2.27)

1.50 (1.35–1.66)

p value for homogeneity*

0.4933

0.0891

0.7393

0.0000

0.2482

0.0000

1

3.06 (2.15–4.35)

1.16 (0.86–1.57)

1.86 (1.48–2.32)

1.22 (0.99–1.50)

1.19 (0.93–1.51)

1.22 (1.04–1.43)

2

2.72 (1.98–3.73)

2.02 (1.57–2.60)

2.26 (1.86–2.76)

1.89 (1.59–2.25)

0.75 (0.62–0.91)

1.27 (1.12–1.44)

3

2.46 (1.90–3.20)

1.80 (1.46–2.22)

2.07 (1.75–2.44)

1.27 (1.08–1.50)

0.90 (0.77–1.05)

1.07 (0.96–1.20)

4

2.74 (2.15–3.50)

1.67 (1.37–2.04)

2.08 (1.78–2.42)

1.05 (0.90–1.23)

0.89 (0.77–1.04)

0.97 (0.87–1.08)

Male

Female

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

Income

RR for 1989 versus 1974/75

Quintile

10–14 y

15–19 y

10–19 y

10–14 y

15–19 y

10–19 y

5

1.91 (1.57–2.32)

1.59 (1.32–1.92)

1.75 (1.53–2.00)

1.05 (0.91–1.20)

0.81 (0.69–0.95)

0.92 (0.83–1.02)

0.0154

0.0361

0.0487

0.0000

0.0399

0.0005

p value for homogeneity* * MH- X

2

RR for 2002/03 versus 1989

for linear trend.

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

among females was reversed and adolescents from the two highest-income groups had lower rates of overweight and obesity than their same-income counterparts in 1989.

Discussion To our knowledge no previous studies have analyzed the trends in the relative weight status of Brazilian adolescents using a national sample and taking into account height and BMI across socioeconomic position. Our analyses suggest a longitudinal increasing trajectory of height, weight, BMI, and overweight/obesity among adolescent males from 1974/75 to 2002/03. The data suggest that young males are becoming more overweight and obese no matter what their age group or socioeconomic position may be. Conversely, the trajectory among young females suggests a reverse in the trend observed among males, with the increase in overweight and obesity being more characteristically located among the older and richest adolescent girls. (p.149) From 1974/75 to 2002/03 there was a five-fold increase in overweight and obesity prevalence in adolescent males and this trend was observed in line with similar trends among adult males in Brazil (Gordon-Larsen et al., 2004). The trends in our current analyses are also in agreement with other studies describing the weight status of adolescents in Brazil (Monteiro et al., 2002; da Veiga et al., 2004). Among the females in the current study, the trend from first to the second time period is compatible with those observed in adult females in Brazil (Monteiro et al., 2000; Monteiro et al., 2002; Monteiro et al., 2004). The recent data among Brazilian adolescents are different from those observed in Europe (Lobstein & Frelut, 2003) and USA (Hedley et al., 2004; Ogden et al., 2006) with a lower prevalence and annual increase (Wang & Lobstein, 2006). The prevalence of overweight and obesity in Brazil is lower than those in other Latin American countries, including Chile (Muzzo et al., 2004), Mexico (Salazar-Martinez et al., 2006), and they are similar to a study of school children from Bogota in Colombia (McDonald et al., 2009). The trends in overweight and obesity among Brazilian children and adolescents are characterized by a downward prevalence among more wealthy females and an increased prevalence among a cross section of income groups among males. Such gender differences are not easily explained. Aesthetic body image concerns, current standards of beauty, and cultural norms encouraging pro-slimness probably play an influential role in promoting the trend towards slimness among young women (da Veiga et al., 2004) but it is hardly sufficient to impact upon the whole female group at population level as seen in our results. In order to explain our results, we suggest the following three vectors that have occurred in Brazil during the time frames of our study 1 Improved access to health and school services observed in Brazil in past decades (Monteiro et al., 2009; Monteiro, 2003) 2 Increases in height observed in Brazilian adolescents over last decades, and

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

3 Concerns about aesthetics, body image, and cultural norms of slimness denoting a desired standard of beauty. It is worth noting two studies, which support our hypotheses. First, there is a recognized positive association between the amounts of schooling and obesity among adult females in Brazil, independent of income (Monteiro et al., 2001). Second, there is evidence that the growth in height experienced by male and female adolescents in our study reflects general body mass gain, nutritional improvements in infancy, and greater access to health services (Monteiro et al., 2009). We suggest that pubertal peak height growth among males and females may present as an overall increase in BMI and therefore, increased overweight in the current study. As height increase in adolescence is interpreted as a mark of exposure to sound nutrition and good health conditions in childhood and infancy, it may be plausible to explain some of the increased overweight as an increase in height resulting from continuous exposure to improved socioeconomic conditions and health access. The expansion in height among Brazilian children and adolescents in our study also occurs simultaneously with a phase in which the older adolescent females were exposed to weight and body image influences, including aesthetic concerns. These factors may partially explain the decrease in female overweight that occurred in our study. Further research will be conducted to study the trends in weight and body image among Brazilian adolescents. We also intend to further examine how social and economic changes impact upon the nutritional and weight status of Brazilian children and adolescents at a population level.

(p.150) Conclusions The figures from research studies conducted in Brazil from 1974 to 2003 suggest secular changes in overweight and obesity among Brazilian adolescents. Our findings suggest that the prevalence of overweight and obesity has increased among all income groups of boys and that there appears to be no slowing of this increase. In girls, the prevalence of overweight and obesity has increased in the past, but this has decreased recently, with a tendency to stabilize or decrease over the last 13 years, especially among older adolescent girls. New and more detailed studies are necessary to accurately describe the secular changes in Brazil and to further examine the hypothesis presented, that better social conditions, improved infant health, greater education, and increased access to nutrition is producing an increase in growth and height among children and adolescents, which generally results in an increase in the overweight prevalence. Body image concerns could further explain the recently observed decrease in overweight and obesity among young women. The decreasing prevalence of overweight and obesity among older adolescent girls and adult women should be investigated more carefully. References Bibliography references:

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

Cole, T.J. et al. (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320(7244), 1240. da Veiga, G.V., da Cunha, A.S., & Sichieri, R. (2004) Trends in overweight among adolescents living in the poorest and richest regions of Brazil. American Journal of Public Health 94(9), 1544. del Río-Navarro, B.E. et al. (2004) The high prevalence of overweight and obesity in Mexican children. Obesity Research 12(2), 215. Dietz, W.H. (1998) Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics 101(3), 518–525. Ford, E.S. & Mokdad, A.H. (2008) Epidemiology of obesity in the western hemisphere. The Journal of Clinical Endocrinology and Metabolism 93(11_Supplement_1), s1–8. Freedman, D.S. et al. (1999) The relation of overweight to cardiovascular risk factors among children and adolescents: the Bogalusa Heart Study. Pediatrics 103(6), 1175. Gordon-Larsen, P. et al. (2004) Five-year obesity incidence in the transition period between adolescence and adulthood: the National Longitudinal Study of Adolescent Health. American Journal of Clinical Nutrition 80(3), 569–575. Hedley, A.A. et al. (2004) Prevalence of overweight and obesity among US children, adolescents, and adults, 1999–2002. JAMA: the Journal of the American Medical Association 291(23), 2847– 2850. Lobstein, T. & Frelut, M.L. (2003) Prevalence of overweight among children in Europe. Obesity Reviews 4(4), 195–200. McDonald, C.M. et al. (2009) Overweight is more prevalent than stunting and is associated with socioeconomic status, maternal obesity, and a snacking dietary pattern in school children from Bogota, Colombia. Journal of Nutrition 139(2), 370–376. Monteiro, C.A. (2003) A dimensão da pobreza, da desnutrição e da fome no Brasil. Estudos Avançados 17, (48). Available at: [Accessed January 14, 2010]. Muzzo, S. et al. (2004) Trends in nutritional status and stature among school-age children in Chile. Nutrition 20(10), 867–872. Monteiro, C.A., Conde, W.L., & Popkin, B.M. (2001) Independent effects of income and education on the risk of obesity in the Brazilian adult population. Journal of Nutrition 131(3), 881S–886S. Monteiro, C.A., Conde, W.L., & Popkin, B.M. (2002) Trends in under- and overnutrition in Brazil. In B.M. Popkin & B. Caballero (Ed.) The nutrition transition: diet and disease in the developing world 1st ed., Academic Press.

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Secular changes in overweight and obesity among Brazilian adolescents from 1974/75 to 2002/03

Monteiro, C.A., Conde, W.L., & Popkin, B.M. (2004) The burden of disease from undernutrition and overnutrition in countries undergoing rapid nutrition transition: a view from Brazil. American Journal of Public Health 94(3), 433–434. Monteiro, C.A. et al. (2000) Shifting obesity trends in Brazil. European Journal of Clinical Nutrition 54(4), 342–346. Monteiro, C.A. et al. (2009) Causes for the decline in child under-nutrition in Brazil, 1996–2007. Revista de Saúde Pública [online] 43(1). Ogden, C.L. et al. (2006) Prevalence of overweight and obesity in the United States, 1999–2004. JAMA: the Journal of the American Medical Association 295(13), 1549–1555. Salazar-Martinez, E. et al. (2006) Overweight and obesity status among adolescents from Mexico and Egypt. Archives of Medical Research 37(4), 535–542. Szklo, M. & Nieto, F.J. (2007) Epidemiology, Jones & Bartlett Publishers. Wang, Y. & Lobstein, T. (2006) Worldwide trends in childhood overweight and obesity. International Journal of Pediatric Obesity 1(1), 11–25.

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Trends in obesity and hypertension in South African youth

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Trends in obesity and hypertension in South African youth K.D. Monyeki H.C.G. Kemper J.W.R. Twisk

DOI:10.1093/acprof:oso/9780199572915.003.0013

Abstract and Keywords Indirect causes of childhood obesity are complex and are sometimes linked to psychological factors, social expectation or pressure, and fat stigmatization. Obesity in children may also be somewhat attributed to psychological stress such as low esteem, poor peer acceptance, and low participation in social and sport activities. However, in some African cultures, particularly those living in rural areas and a minority in urban areas who still follow indigenous knowledge, obesity in both children and adults is regarded as a sign of wealth, status, and physical attractiveness. This chapter reviews child and youth obesity (aged between 1 and 24 years) and hypertension trends and prevention strategies in South Africa, using individual studies conducted in both rural and urban settings and the national studies during the 21st century.

Keywords: children, adolescents, epidemiology, psychological stress, Africa, South Africa, hypertension, blood pressure

Chapter summary Indirect causes of childhood obesity are complex and are sometimes linked to psychological factors, social expectation or pressure, and fat stigmatization. Obesity in children may also be somewhat attributed to psychological stress such as low esteem, poor peer acceptance, and low participation in social and sport activities. However, in some African cultures, particularly those living in rural areas and a minority in urban areas who still follow indigenous knowledge, obesity in both children and adults is regarded as a sign of wealth, status, and physical attractiveness. The purpose of this chapter is to review child and youth obesity (aged between 1 and 24 years)

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Trends in obesity and hypertension in South African youth

and hypertension trends and prevention strategies in South Africa, using individual studies conducted in both rural and urban settings and the national studies during the 21st century.

Introduction The association of obesity with an increased risk of chronic diseases, particularly cardiovascular diseases, of lifestyle in adults, is well known (Ho, 2009; Kemper, 2004; Opie & Mayosi, 2005; Twisk et al., 1998). One of the most important cardiovascular diseases in relation to obesity is hypertension. Risk estimated from population studies suggests that more than 75% of hypertension cases can be directly attributed to obesity (Kemper, 2004). An increasing blood pressure in obese adults can be attributed to left ventricular hypertrophy (Messerli, 1982). However, there is increasing evidence, which shows a strong link between childhood obesity and cardiovascular diseases (Kemper et al., 1999; Must et al., 1992). The obese children were three times more likely to present hypertension after adjusting to confounding factors (Ho, 2009). Furthermore, in a case control study of young children aged 0.1 to 6.9 years in China, 19.4% of children in the obese group had blood pressure values above the 95th percentile as contrasting with 7.0% of the non- obese children (He et al., 2000). South Africa is currently experiencing rapid urbanization, especially Africans leaving underdeveloped rural areas to seek a better lifestyle in and around the cities. In 1993, 48% of the South African population was urbanized compared to more than 60% in 2000 (Statistics South Africa, 2002). Childhood obesity is or may become a public health problem because of rapid urbanization and westernization processes currently taking place. Popkin and Doak (1998) and Bar-Or et al. (1998) report that influx urbanization, which leads to a decrease in participation in physical activity of youth due to an unsafe environment, and an increase in consumption of fast food high in fat and sugar have led to high prevalence of obesity and subsequently hypertension in the developed countries. Individual studies and some few national studies in South Africa provide fragmented evidence on the impact of hypertension and obesity in both rural and urban pediatric population today if considered in isolation. (p.153) Table 13.1 shows a summary of studies of the prevalence of overweight, obesity, and hypertension of South African children aged 1 to 24 years. The largest sample studied consisted of 1629 children (aged 6 to 13 years) (Monyeki et al., 2002) and 1257 children (aged 10 to 15 years) (Kruger et al., 2006) in urban areas and 1817 children (aged 7 to 13 years) (Monyeki et al., 2009) in rural areas. The least number of children studied were 120 children (age 3 to 4) (Du Toit & Pienaar, 2003) and 162 (aged 3 years) (Mamabolo et al., 2005) in urban and rural areas, respectively. A total of 10195 children aged 6 to 13 years was the largest number of children while 2377 (aged 15 to 24 years) was the least number of children studied nationally (Department of Health, 2007; Armstrong et al., 2006) (Table 13.1). In all selected studies except two national studies, hypertension was defined as the occurrence of SBP and DBP levels greater or equal to the 95th percentile of height and sex adjusted reference levels (NHBPEP, 1996;). Department of Health (2002 and 2007) classified subjects as

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Trends in obesity and hypertension in South African youth

hypertensive if they had a systolic blood pressure higher than 140 mmHg and diastolic blood pressure higher than 90 mmHg, as the sample age range in the report covers people aged 65 years and more. However, it is clear from this cut-off point in these two studies that the situation might be worse than it is reported for children aged 15 to 24 years.

Overweight and obesity trends in South Africa Overweight seems to be an emerging public health problem in South Africa. Nationally, the highest recorded prevalence of overweight was above 17% with girls (25%) experiencing the highest prevalence compared to boys (14.3) % (Reddy et al., 2003; Armstrong et al., 2006) (Table 13.1). Interestingly, the highest prevalence of overweight was reported in the rural area (22.0%) for children aged 3 years (Mamabolo et al., 2005). Girls aged 13–18 years were reported to be overweight (12.1%) compared to boys (8.8%) of the same age (Naude et al., 2008). The prevalence of obesity was generally low in South Africa. The highest recorded prevalence of obesity nationally was 11.0% for girls aged 15 to 24 years and 5.8% for boys aged 6 to 13 years (Department of Health, 2007; Armstrong et al., 2006) (Table 13.1). Recently, highest prevalence (30.8%) of obesity was recorded in the urban area for children aged 10 to 16 years (Matsha et al., 2009) while Mamabolo et al. (2005) recorded the highest prevalence (24%) of obesity in rural children aged 3 years.

Hypertension trends in South Africa The prevalence of hypertension was high in urban areas 23.9% (aged 5 years) with girls (21.2%) (age 10 to 15 years) experiencing the highest prevalence compared to boys (12.2%) of the same age group (Steyn et al., 2000; Schutte et al., 2003a, b). In the rural areas the prevalence of hypertension ranged from 3.1 to 11.4% for girls (aged 6 to 13 years), whereas it ranged from 0.5 to 5.8% for boys aged 6 to 13 years (Monyeki et al., 2006a; 2009). Nationally the prevalence of hypertension was high for boys (7.4%) compared to girls (4.1%) in the 1998 national study (Department of Health, 2002) whereas in the 2003 survey, girls (3.5%) were slightly higher than boys (3.4%) even though the significant difference was not tested between them (Department of Health, 2007).

Risk of overweight, obesity, and hypertension among South African children The risk of becoming overweight (Table 13.2) for children (aged 10 to 15 years) in the urban areas was low (OR = 0.50 95%CI 0.21–1.19) compared to children aged 7 to 13 years (OR = 22.1 95%CI 12.3–35.7) of rural areas (Mukhuddem-Petersen & Kruger, 2004; Monyeki et al., 2008a). (p.154)

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Trends in obesity and hypertension in South African youth

Table 13.1 The sample size, age range, and the prevalence of overweight, obesity, and hypertension of South African children aged 1 to 24 years Reference Boys

Girls

Total

Sample size (age range in years)

Overweight

Obesity

Hypertension

Place

Boys %

Girls% Total %

Boys %

Girls %

Total %

Boys Girls % %

Total %

Urban Areas Steyn et al. (2000)#

–

–

964 (5 years)

–

–

–

–

–

–

–

–

23.9

Soweto

Monyeki et al. (2002)*

821 (6–13)

808 (6–13)

1629 (6– 13)

–

3.3– 21.1

–

0.8– 9.6

0–6.6 –

–

–

–

Polokwane

Schutte et al. (2003a)#

321 (10–15)

373 (10–15) 695 (10– 15)

–

–

–

–

–

–

12.5 21.2

17.2

Potchefstroom

Kruger et al. (2006)*

608 (10–15)

649 (10–15) 1257 (10– 15)

4.1

8.3

6.3

1.5

1.7

1.6

–

–

Potchefstroom

Schutte et al. (2003b)#

321 (10–15)

373 (10–15) 695 (10– 15)

–

–

–

–

–

–

12.2 21.5

17.2

Potchefstroom

Naude et al. (2008)*

113 (13–18)

167 (13–18) 280 (13– 18)

8.8

12.1

–

0

3.4

–

–

–

–

Potchefstroom

Du Toit & Pienaar 58 (3–4) (2003)**

62 (3–4)

120 (3–4)

–

–

9.17

–

–

6.7

–

–

–

Potchefstroom

Matsha et al. (2009)

497(10–16 years)

776(10–16 years)

1272

–

–

15.7

–

–

30.8

–

–

–

Western Cape

294– 266 (4.5–11.5)

254–223 (4.5–11.5)

–

0.4– 3.7

0.5–3.9 –

0

0–1.2 –

–

–

–

Ellisras

–

Rural Areas Monyeki et al. (2008a)*

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Trends in obesity and hypertension in South African youth

Reference Boys

Girls

Total

Sample size (age range in years) 901–657 (8.1–14.9)

Overweight

Obesity

Boys %

Girls% Total %

Boys %

Girls %

Hypertension Total %

Place

Boys Girls % %

Total %

776–625 (8.1–14.9)

–

0.3– 4.9

1.6– 15.5

–

0–0.6

0–2.7 –

–

–

–

Ellisras

Monyeki et al. (2006a)*# Makgae et al. (2007)*#

980 (6–13)

922 (6–13)

1802 (6– 13)

0–2.9

0–4.6

–

–

–

–

0– 5.8

3.1– 11.4

–

Ellisras

Mamabolo et al. (2005)*

–

–

162 (3years)

–

–

22

–

–

24

–

–

–

Dikgale

Jinabhai et al. (2003)*

359 (8–11)

443 (8–11)

802 (8–11) 0–4.4

0–11.9 –

0

0–1.5 –

–

–

–

Vulamehlo

Monyeki et al. (2008b)*#

938 (7–13)

879 (7–13)

1817 (7– 13)

0–2.9

0–4.6

–

–

–

1– 5.8

3.1– 11.4

–

Ellisras

Armstrong et al. (2006)*

5611 (6–13)

4584(6–13)

10195 (6– 13)

7.9– 11.7

11.8– 14.3

2.5– 6.0

4.1– 5.8

–

–

–

–

Reddy et al. (2003)*

4213 (13–18) 4931 (13– 18)

9144 (13– 18)

6.9

25.0

17.2

2.2

5.3

4.0

–

–

–

Labadarios et al. (2000)*

–

2200 (1–9) –

–

17.1

–

–

5.0

–

–

–

DOH (2002*)&

1796 (15–24) 2044 (15– 24)

3840 (15– 24)

8.4

20.0

–

2.7

9.6

–

7.4

4.1

–

DOH (2007)*&

1121(15–24) 1256 (15– 24)

2377 (15– 24)

9.7

19.7

–

1.8

11.0

–

3.4

3.5

–

–

National Surveys

–

〈TFNDOH = Department of Health.

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Trends in obesity and hypertension in South African youth

– = Not applicable *=Overweight and obese according to Cole et al. (2000). ## = Hypertension defined as the average SBP and DBP greater or equal to 95th percentile for age and sex. & = Hypertension defined as 149/90 mmHg. ** 85th cut-off point for overweight and 95th cut-off point for obese for BMI according to Must et al. (1991).

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Trends in obesity and hypertension in South African youth

(p.155) (p.156)

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Trends in obesity and hypertension in South African youth

Table 13.2 Age range, odds ratio, and 95% confidence interval for developing the risk of overweight and hypertension in South African children Urban areas References

Rural areas

Age range

OR

95%CI

Age range

Mukhuddem-Petersen & Kruger (2004)*

10–15 years

0.45 0.50

0.16–1.30 Boys 0.21–1.19 Girls

Cameron et al. (2005)**

2–9 years

1.09

0.30–3.98

OR

95%CI

Overweight/ Obesity

Mamabolo et al. (2005)*

3 years

0.64

0.19

Monyeki et al. (2008a)#

4.5–11.5

1.30 1.32

1.219–1.376 Boys 1.232–1.418 Girls

8.1–14.9

1.53 1.85

1.487–1.576 Boys 1.232–1.418 Girls

7–13

22.1

12.3–35.7

Monyeki et al. (2008b)$

2.16

Hypertension Monyeki et al. (2008b)$

7–13

1.1

0.5–2.3

Monyeki et al. (2009)#

7–11

1

1 Boys

2.48

2.36–2.59 Girls

2.69

2.53–2.89 Boys

2.72

2.61–2.8 Girls

11.–14

National study

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Trends in obesity and hypertension in South African youth

Urban areas

Rural areas

References

Age range

OR

95%CI

Steyn et al. (2005)@

1–9

1.44

1.09–1.89

Age range

OR

* = Children who are stunted have the risk of being overweight and obese. # = The risk derived from general estimated equation for overweight and hypertension separately in a longitudinal study. $= Children with the waist girth above the 90th percentile have a risk of having hypertension and being overweight. @ = Mantel–Haenszel method for the risk of being overweight or obese while staying in a mud or traditional house. ** The risk of stunting at 2 years as a predictor of overweight at 7 to 9 years.

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95%CI

Trends in obesity and hypertension in South African youth

Interestingly, the risk of children (aged 1 to 9 years) becoming overweight in a mud or traditional house was OR = 1.44 95%CI 1.09–1.89 (Steyn et al., 2005). Cameron et al. (2005) reported the risk of urban children at 2 years to be overweight, at 7 to 9 years to be low and insignificant (OR = 1.09 95%CI 0.30–3.98). In rural areas the risk of becoming hypertensive over time was almost similar for both boys and girls (OR = 2.69 95%CI 2.53–2.89 for boys and OR = 2.72 95%CI 2.61–2.80 for girls) (Monyeki et al., 2009).

Comparison of South African results with those of other countries Selection of studies in Africa and other parts of the world, which was used for comparison in the current chapter, was based on the same definition of hypertension and obesity as used in selected South African literature. In Morroco, the prevalence of overweight children under 5 years (9.5% for boys and 8.8% for girls, 10.1% for urban children and 8.6% among rural children) was low compared to the South African children of the same age group (Rguibi & Belahsen, 2007). Children aged 10 to 19 years studied in Egypt (overweight =18.8%; obesity = 2.1%), Kuwait (p.157) (overweight = 33.1% and obesity = 12.2%) and Lebanon (overweight = 35.9% and obesity = 11.1%) were more overweight and obese than the South African children of the same age group (Jackson et al., 2007). The prevalence of overweight for Mexican children aged 11 to 14 years (overweight = 20.3%, obesity = 12.9%) was similar to that of the South African children (Table 13.1) but Egyptian children (overweight = 7.2%, obesity = 6.6%) of the same age had low prevalence of overweight and obesity compared to South African children (Salazar-Martinez et al., 2006). Higher age group (15–19 years) in Mexican children (overweight = 13.2%, obesity = 8%) and Egyptian children (overweight = 6.5%, obesity = 5.9%) had low prevalence of overweight and obesity as compared to South African children (Salazar-Martinez et al., 2006). Waters et al. (2008) reported high prevalence of overweight (aged 4–8 years = 28.3%; aged 9–13 years = 33.6%) and obese (aged 3–8 years = 9.0%; aged 9–13 years = 9.3%) for Australian children aged 4 to 8 years and aged 9 to 13 years compared to South African children of similar age groups. O’Dea (2003 and 2008) reported almost similar prevalence trends of overweight (16.2 to 23.2% for age 6 to 11/12 years and 16.4 to 17.6% for age 12/13 to 18 years) and obesity (4.3% to 8.8% aged 6 to 13 years and 6.5 to 10.1% aged 13 to 18 years) for low to high socioeconomic status Australian children to the South African children of the same age group. Limited studies in Africa were found for the prevalence of hypertension. The majority of the studies found could not meet the selection criteria as stated earlier. Addo et al. (2006) reported the prevalence of hypertension of children below 25 years to be 6%, which was low compared to the South African children. Almost similar trends as that of the South African children aged 14 to 25 years was reported among the Asian boys (20.0%) and not the girls (13.2%) (Misra et al., 2006). Barba et al. (2006) reported the prevalence of hypertension in Italian children (boys = 9.9%, girls = 13.9%) aged 6 to 11 years to be low compared to urban South African children but high compared to rural South African children of the same age.

Underlying mechanism of overweight, obesity, and hypertension In South Africa the prevalence of overweight was high among adolescent children. Specifically, prevalence was high among adolescent girls (age 13 to 18 years) (25%) who had the highest reported prevalence of overweight in the 21st century (Reddy et al., 2003). Coincidentally, the

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Trends in obesity and hypertension in South African youth

prevalence of hypertension was also high among adolescent girls (21.5%) (aged 10 to 15 years) compared to boys (12.5%) (Schutte et al., 2003a,b). Surprisingly, the prevalence of obesity was high (24%) among rural children (age 3 years) (Mamabolo et al., 2005). Obese and overweight children may become obese, overweight, and hypertensive adults (Kemper, 2004). The development of obesity or overweight has been linked to four critical stages or sensitive periods: intra-uterine life, infancy, the periods of adipose rebound (5–7 years), and adolescence (Dietz, 1994). The onset of obesity or overweight during one or more of these periods appears to increase the risk of overweight-related conditions, such as hypertension later in life (Kemper et al., 1999). Furthermore, adolescence is also known to be an important stage to develop central patterning of body fat, which predisposes to cardiovascular diseases at a later age (van Lenthe et al., 1998). It is interesting to note that rural children develop overweight at a younger age (age 3 years) (Mamabolo et al., 2005). It is clear that in South Africa, overweight and obesity tend to be more common among girls. The underlying mechanism to this phenomenon may also be the acquisition of gluteo-femoral fat patterns in females, which appears to be dependent on cortisol and sex steroid hormones, particularly progesterone (Cameron, 1997; Bojorntor, 1992) as well as successive pregnancies. Sex steroids, mainly progesterone, increase the prevalence of obesity in black females following menarche particularly at the gluteo-femoral site (Cameron, 1997). Furthermore, it has been (p. 158) suggested that small size at birth in full-term pregnancies is linked with subsequent development of the major features of the metabolic syndrome, namely, glucose intolerance, an increase in blood pressure, dyslipidaemia, and increased mortality from cardiovascular diseases (Barker, 2006; Barker et al., 1989). A genetic basis for both obesity and hypertension appears to exist in the African population (Brink et al., 2009; Rejeb et al., 2008; Sile et al., 2009). Environmental factors (gender, education, urbanization, body mass index, family history, and excessive alcohol use) were shown to be associated with obesity and hypertension in adults (Kemper, 2004; Steyn et al., 2006). In children, Levitt et al. (1999) reported that the systolic blood pressure of children aged 5 years was inversely related to birth weight independent of the current weight, height, gestational age, or socioeconomic status. Furthermore, biotin, folic acid, pantothenic acid, zinc, and magnesium were significantly associated with blood pressure in hypertensive boys (aged 10 to 15 years) whereas for hypertensive girls (aged 10–15 years) energy intake, biotin, and Vitamin A were associated with higher blood pressure (Schutte et al., 2003a). In the Amsterdam Growth and Health Longitudinal study report, physical activity was an important predictor of adult bone mineral density and serum HDL-cholesterol; hence promotion of habitual physical activity in the adolescent period seems effective in the early prevention of obesity and hypertension later in life (Kemper et al., 1999; van Mechelen et al., 1999).

Possible explanations for South African results of hypertension and obesity trends The risk of developing hypertension and overweight over time was significant in both South African rural boys and girls (aged 4 to 14 years) (Monyeki et al., 2008a,b; Monyeki et al., 2009). Similar trends were reported for South African urban children aged 10 to 15 years (Mukhuddem-Petersen & Kruger, 2004). Dwelling condition for children aged 1 to 9 years

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Trends in obesity and hypertension in South African youth

particularly for the low socioeconomic status (parents staying in mud or traditional houses) or people mostly living in rural areas does pose an increased risk of becoming overweight (Steyn et al., 2005). Many social and economic changes are taking place in South Africa today, which may be of concern regarding child health status. These include the adoption of Western diets, which are high in saturated fats, sugar, and refined food and changing lifestyles, which include among others, reduced level of physical activity, tobacco, and an increased level of alcohol and stress (Kruger et al., 2006; Labadarios et al., 2000; Monyeki & Kemper, 2008; Steyn et al., 2005). This phenomenon has been labeled ‘Nutrition Transition’ by Popkin (1994), and it is the probable cause of the emerging obesity and hypertension in South Africa. Children are exposed to these influences, and the impact of this influence increases with age. Cultural perception of body size and old age contributes to the escalating prevalence of obesity and mortality in South Africa. A large body size has many positive connotations in black communities, particularly in rural areas together with a few urban populations who are still rooted in the indigenous knowledge. A large body size may be associated with affluence or wealth, good health, attractiveness, and happiness in this population whereas very old people (about over 55 years) in the community are labeled as witchdoctors by the youth (Monyeki, 2000). In addition, there is a stigma attached to the syndrome of weight loss as it is associated with HIV/AIDS infection in the community (Howson et al., 1996). Against this background, Africans experience less pressure from partners, relatives, and friends to reduce body weight and to increase their life expectancy by following a healthy lifestyle. This African perception of overweight and obesity was left unchallenged for too long. This is contrary to the perception from developed countries of overweight people who are seen as failures, deviants or moral outcasts, weak minded, ugly, lazy, (p.159) bad, stupid, and worthless (O’Dea, 2005; Schwartz et al., 2003). Though there is a paradigm shift in cultural perception for men and women to reduce their body sizes for the improvement of health and community becoming aware of mortality emanating from chronic diseases, illiteracy should be the first hurdle to be jumped by health professionals to acquire this goal to all the sectors of the community. The South African population should not be in compliance with what they have in terms of traditional knowledge and medicine, but rather seek new innovative ways of addressing issues facing the population in terms of health, climate, environment, and lifestyle changes in the ongoing political transformation. The rural population is characterized by consumption of low food energy, high consumption of wild animal meat, and the high usage of indigenous tobacco, drugs, and alcohol products (Monyeki, 2000; Steyn et al.,1992). The urban population is characterized by high consumption of fast food rich in sugar, fat and the high usage of contemporary tobacco, alcohol, and drug products (Department of Health, 2007; Temple et al., 2008). Access to primary health care, eradication of illiteracy, knowledge of a healthy diet, and the elimination of language barriers in the implementation of the research results to the communities could have a beneficial influence on the lifestyle change of the community (Kemper, 2004; Monyeki & Kemper, 2008; Yusuf et al., 2001).

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Trends in obesity and hypertension in South African youth

Conclusions South Africa is in a state of epidemiological transition with chronic diseases playing a major role in increasing mortality rates. Healthy, active, well-nourished children are a fundamental prerequisite for sustained economic development in any society. The dominant factors driving success are the will to deliver first-class cardiovascular care within the limits of cost effectiveness and the need to build a suitable infrastructure, for example, an introduction of community health workers. The government has the responsibility to support their citizens in their pursuit of a healthy long life. It is not enough to say that we have told them not to smoke, take alcohol, or drugs, refrain from eating saturated fat, reduce salt and sugar intake in their diet, take regular exercise and eat fruits and vegetables. Together with the ministries of health we (government administrators and officials, scientists, educators, community leaders, pediatricians, general practitioners, dietitians, parents, and children) must create regular community, workplace, and market forums that make these healthy choices possible.

Acknowledgement The financial support received from South African Medical Research Council and National Research Foundation is thankfully acknowledged. Any opinion, findings and conclusions or recommendations expressed in this material are those of the authors and therefore the above mentioned funding sources do not accept any liability in regard thereto. The authors are in dept to Ellisras Longitudinal Study administrators for providing technical support in preparation of this manuscript. Monyeki MS and Malatji MJ (Makgoka High School, Limpopo Province) are thankfully acknowledged for editing this manuscript. References Bibliography references: Addo, J., Amoah, A.G.B., & Koram, K. (2006) The changing patterns of hypertension in Ghana: a study of four rural communities in the GA district. Ethnicity & Disease 16, 895–900. Armstrong, M.E.G., Lambert, M.I., Sharwood, K.A., & Lambert, E.V. (2006) Obesity and overweight in South African primary school children – The Health of the Nation Study. South African Medical Journal 96(5), 439–444. Barba, G., Troiano, E., Russo, P., Strazzullo, P., & Siani, A. (2006) On behalf of ARCA Project Study Group. Body mass, fat distribution and blood pressure in Southern Italian children: results of ARCA project. Nutrition, Metabolism, and Cardiovascular Diseases 16, 239–248. Bar-Or, O., Foreyt, J., Bouchard, C., & Brownell, K.D. (1998) Physical activity, genetic and nutritional considerations in childhood weight management. Medicine and Science in Sports and Exercise 30(1),2–10. Barker, D.J.P. (2006) Commentary: birth weight and coronary heart disease in a historical cohort. International Journal of Epidemiology 35(4), 880–885. Barker, D.J.P., Osmond, C., Golding, J., Kuh, D., & Wadsworth, M.E. (1989) Growth in utero, blood pressure in childhood and adult life and mortality from cardiovascular diseases. BMJ 298, 564–567.

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Brink, P.A., Moolman-Smook, J.C., & Corfield, V.A. (2009) Mendelian-inherited heart disease: a gateway to understanding mechanisms in heart disease. Update on work done at the University of Stellenbosch. Cardiovascular Journal of Africa 20(1), 57–63. Bojorntor, P. (1992) Regional obesity. In P. Bjortorp & B.N. Brodoff (Ed.) Obesity. Philadelphia: Lippincot, pp. 579–586 Cameron, N. (1997) African obesity – a puzzle solved. South African Medical Journal 87, 1396– 1397. Cameron, N., Wright, M.M., Griffiths, P.L., Norris, S.A., & Pettifor, J.M. (2005) Stunting at 2 years in relation to body composition at 9 years in African urban children. Obesity Research 13(1), 131–136. Cole, T.J., Bellizzi, M.C., Flegal, K.M., & Dietz, W.H. (2000) Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320, 1240–1243. Department of Health (2002) South Africa Demographic and Health Survey 1998. Department of Health, Pretoria, pp. 156–162. Department of Health, Medical Research Council, & OrcMacro (2007) South Africa Demographic and Health Survey 2003. Department of Health, Pretoria, pp. 243–277. Dietz, W.H. (1994) Critical period in childhood for the development of obesity. American Journal of Clinical Nutrition 59, 955–959. Du Toit, D. & Pienaar, A.E. (2003) Overweight and obesity and motor proficiency of 3- and 4year-old children. South African Journal for Research in Sports, Physical Education and Recreation 25(2), 37–48. He, Q., Ding, Z.Y., Fong, D.Y., & Karlberg, J. (2000) Blood pressure in association with body mass index in both normal and obese children. Hypertension 36, 165–170. Ho, F.T. (2009) Cardiovascular risks associated with obesity in children and adolescents. Annals Academy of Medicine 38, 48–56. Howson, P.C., Harrison, P.F., Hotra, D., & Law, M. (1996) In her lifetime. Female morbidity and mortality in Sub-Saharan Africa. National Academy Press, Washington, pp. 183–198. Jackson, R.T., Rashed, M., Al-Hamad, N., Hwalla, N., & Al-Somale, M. (2007) Comparison of BMI-for-age in adolescent girls in 3 countries of the Eastern Mediterranean region. Eastern Mediterranean Health Journal 13(2), 430–440. Jinabhai, C.C., Taylor, M., & Sullivan, K.R. (2003) Implications of the prevalence of stunting, overweight and obesity amongst South African primary school children: a possible nutritional transition. European Journal of Clinical Nutrition 57, 358–365.

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Kemper, H.C.G. (2004) Amsterdam growth and Health longitudinal study: A 23 year follow up from teenager to adult about lifestyle and health. Karger, New York, pp. 1–20. Kemper, H.P., Post, G.B., Twisk, J.W., & van Mechelen, W. (1999) Lifestyle and obesity in adolescent and young adulthood: results from Amsterdam Growth and Health Longitudinal Study (AGAHLS). International Journal of Obesity 23 (Suppl 3), S34–40. Kruger, R., Kruger, H.S., & MacIntyre, U.E. (2006) The determinants of overweight and obesity among 10–15 year old schoolchildren in the North West Province, South Africa – the Thusa Bana (Transition and Health during urbanization of South Africans; BANA, children) study. Public Health Nutrition 9(3), 351–358. Labadarios, D., Steyn, N.P., Maunder, E., et al. (2000) The National Food Consumption Survey: Children aged 1–9 years, South Africa, 1999. Department of Health, Pretoria (Chapter ). Levitt, N.S., Steyn, K., De Wet, T., et al. (1999) An inverse relation between blood pressure and birth weight among 5 year old children from Soweto, South Africa (Birth to Ten Study). Journal of Epidemiology & Community Health 53, 264–268. Makgae, P.J., Monyeki, K.D., Brits, S.J., Kemper, H.C.G., & Mashita, J. (2007) Somatotype and cardiovascular functions of rural South African children aged 6 to 13 years: Ellisras Longitudinal Growth and Health study. Annals of Human Biology 34(2), 240–251. Mamabolo, R.L., Alberts, M., Steyn, N.P., Delemarre-van de Waal, H.A., & Levitt, N.S. (2005) Prevalence and determinant of stunting and overweight in 3 year old black South African children residing in the Central Region of Limpopo Province, South Africa. Public Health Nutrition 8(5), 501–508. Matsha, T., Hassan, S., Bhata, A., et al. (2009) Metabolic syndrome in 10–16 year-old leaners from the Western Cape, South Africa: Comparison of the NCEP ATP III and IDF criteria. Atherosclerosis 205, 363–366. Messerli, F.H. (1982) Cardiovascular effects of obesity and hypertension. Lancet 1, 1165–1168. Misra, A., Madhavan, M., Vikram, N.K., Pandey, R.M., Dhingra, V., & Luthra, K. (2006) Simple anthropometric measures identify fasting hyperinsulinemia and clustering of cardiovascular risk factors in Asian Indian adolescents. Metabolism: Clinical and Experimental 55, 569–1573. Monyeki, K.D. (2000) Tracking physical growth and health status of South African rural children: Ellisras Longitudinal Growth and Health Study. PhD thesis. Potchefstroom University for CHE, Potchefstroom. Monyeki, K.D., Kemper, H.C.G., & Makgae, P.J. (2006a) The association of fat patterning with blood pressure in rural South African children: The Ellisras Longitudinal Growth and Health Study. International Journal of Epidemiology 35(1), 114–120.

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Monyeki, K.D., Makgae, P.J., Motlokoa, G.L., Mashita, R.L., & Amusa, L.O. (2006b) Reporting health care research in South Africa: which categorization is most appropriate? African Journal for Physical, Health Education, Recreation and Dance 12(2), 171–181. Monyeki, K.D., Steyn, N.P., & Monyeki, M.A. (2002) Body composition in urban black South African school children aged 6 to 13 years. African Journal for Physical, Health Education, Recreation and Dance 8(2), 285–296. Monyeki, K.D. & Kemper, H.C.G. (2008) The risk factors for elevated blood pressure and how to address cardiovascular risk factors: a review in pediatric population. Journal of Human Hypertension 22, 450–459. Monyeki, K.D., Monyeki, M.A., Brits, S.J., Kemper, H.C.G., & Makgae, P.J. (2008a) Development and tracking of body mass index from preschool aged into adolescence in rural South African children: Ellisras Longitudinal Growth and Health Study. Journal of Health Population and Nutrition 26(4), 405–417. Monyeki, K.D., Kemper, H.C.G., & Makgae, P.J. (2008b) Relationship between fat patterns, physical fitness and blood pressure of rural South African children: Ellisras Longitudinal Growth and Health Study. Journal of Human Hypertension 22, 311–319. Monyeki, K.D., Kemper, H.C.G., Twisk, J.W.R., Makgae, P.J., Mashita, J., & Traville, A. (2009) Longitudinal development and tracking of risk indicators for cardiovascular diseases of rural South African children: The Ellisras Longitudinal Growth and Health Study. Has been published on the 6th International Congress of Cardiology through the Internet- 6th Virtual Congress of Cardiology, held on the Intranet from 1st September to 30 November 2009. ISBN: 978–987– 22746–1–0. Mukhuddem-Petersen, J. & Kruger, H.S. (2004) Association between stunting and overweight among 10–15 year old children in the North West Province of South Africa: the THUSA BANA study. International Journal of Obesity 28, 842–851. Must, A., Dallal, G.A., & Dietz, W.H. (1991) Reference data for obesity: 85th and 95th percentiles of body mass index and triceps skinfold thickness. American Journal of Clinical Nutrition 53, 839–846. Must, A., Jacques, P.F., Dallal, G.E., Bajema, C.J., & Dietz, W.H. (1992) Long-term morbidity and mentality of overweight adolescent: a follow-up of the Harvard growth study of 1922 to 1935. The New England Journal of Medicine 327, 1350–1355. National High Blood Pressure Education Program (NHBPEP) Working Group on Hypertension Control in Children and Adolescents. (1996) Update on the 1987 task force report on high blood pressure in children and adolescents: a working group report from the National High Blood Pressure Education Program. Pediatrics 98, 649–658.

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National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents (2004) The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 114, 555–576. Naude, D., Kruger, H.S., Pienaar, A.E., & Mamabolo, R.L. (2008) Body fat, body mass index in black South African adolescents after a physical activity intervention program: Play study. African Journal for Physical, Health Education, Recreation and Dance 14(4), 440–455. O’Dea, J.A. (2003) Differences in overweight and obesity among Australian schoolchildren of low and middle/high socioeconomic status. The Medical Journal of Australia 179(1), 63. O’Dea, J.A. (2005) Prevention of child obesity: ‘First, do no harm’. Health Education Research 20(2), 259–265. O'Dea, J.A. (2008) Gender, ethnicity, culture and social class influences on childhood obesity among Australian schoolchildren: implications for treatment, prevention and community education. Health and Social Care in the Community 16(3), 282–290. Opie, L.H. & Mayosi, B.M. (2005) Cardiovascular disease in Sub-Saharan Africa. Circulation 112, 3536–3540. Popkin, B.M. (1994) The Nutrition transition in low-income countries: an emerging crisis. Nutrition Review 52(9), 285–298. Popkin, B.M. & Doak, C.M. (1998) The obesity epidemic is a worldwide phenomenon. Nutrition Reviews 56(4),106–114. Reddy, S.P., Panday, S., Swart, D., et al. (2003) Umthenthe Uhlaba Usamila – The South African Youth Risk Behavior Survey 2002. South African Medical Research Council, Cape Town, pp. 122–123. Rejeb, J., Omezzine, A., Rebhi, L., et al. (2008) Association of the cholesteryl ester transfer protein Taq1 B2B2 genotype with higher high-density lipoprotein cholesterol concentrations and lower risk of coronary artery disease in a Tunisian population. Archives of Cardiovascular Diseases 101(10), 629–636. Rguibi, M. & Belahsen, R. (2007) National prevalence of obesity: prevalence of obesity in Morocco. Obesity Reviews 8, 11–13. Salazar-Martinez, E., Allen, B., Fernandez-Ortega, C., Torres-Mejia, G., Galal, O., & LazcanoPonce, E. (2006) Overweight and obesity status among adolescents from Mexico and Egypt. Archives of Medical Research 37, 535–542. Schutte, A.E., van Rooyen, J.M., Huisman, H.W., Kruger, H.S., Malan, N.T., & De Ridder, J.H. (2003a) Dietary risk markers that contribute to the aetiology of hypertension in black South African children: the THUSA BANA study. Journal of Human Hypertension 17, 29–35.

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Schutte, A.E., van Rooyen, J.M., Huisman, H.W., Kruger, H.S., & Malan, N.T. (2003b) The potential role of biotin as dietary risk marker for hypertension in black South African children – the THUSA BANA study. South African Journal of Clinical Nutrition 16(4), 144–148. Schwartz, M.B., Chambliss, H.O., Brownell, K.D., Blair, S.N., & Billington, C. (2003) Weight bias among health professionals specializing in obesity. Obesity Research 11(9), 1033–1039. Sile, S., Velez, D.R., Gillani, N.B., et al. (2009) CLCNKB-T481S and essential hypertension in a Ghanaian population. Journal of Hypertension 27(2), 298–304. Statistics South Africa (2002) Cause of death in South Africa 1997–2001: Advance release of records of death. Statistics South Africa, Pretoria, pp. 18–42. Steyn, N.P., Badenhost, C.J., Nel, J.H., & Jooste, P.L. (1992) The nutritional status of Pedi preschool children in two rural areas of Lebowa. South African Journal of Food Science Nutrition 4, 24–28. Steyn, K., De Wet, T., Richter, L., Cameron, N., Levitt, N.S., & Morrell, C. (2000) Cardiovascular diseases risk factors in 5-year-old urban South African children: the Birth to Ten Study. South African Medical Journal 90(7), 719–725. Steyn, N.P., Labadarios, D., Maunder, E., Nel, J., Lombard, C., & Directors of the National Food Consumption Survey. (2005) Secondary anthropometric data analysis of the national food consumption survey in South Africa: the double burden. Nutrition 21, 4–13. Steyn, K., Fourie, J., & Temple, N. (2006) Chronic diseases of lifestyle in South Africa: 1995– 2005. Technical report, Medical Research Council, Cape Town, pp. 121–173. Temple, N.J., Steyn, N.P., & Nadomane, Z. (2008) Food advertisement on children’s program on TV in South Africa. Nutrition 24, 781–782. Twisk, J.W.R., Kemper, H.C.G., van Mechelen, W., Post, G.B., & van Lenthe, F.J. (1998) Body fatness: longitudinal relationship of body mass index and the sum of skinfolds with other risk factors for coronary heart disease. International Journal of Obesity 22, 915–922. Van Mechelen, W., Twisk, J.W., Kemper, H.C., Snel, J., & Post, G.B. (1999) Longitudinal relationship between lifestyle and cardiovascular and bone health status indicators in males and females between 13 and 27 years of age: a review of findings from the Amsterdam Growth and Health Longitudinal Study. Public Health Nutrition 2(3A), 419–427. Van Lenthe, F.J., Kemper, H.C.G., & Twisk, J.W.R. (1994) Tracking blood pressure in children and youth. American Journal of Human Biology 6, 389–399. van Lenthe, F.J., van Mechelen, W., Kemper, H.C., & Twisk, J.W. (1998) Association of a central pattern of body fat with blood pressure and lipoproteins from adolescence into adulthood. The Amsterdam Growth and Health Study. American Journal of Epidemiology 147(7), 686–693.

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Waters, E., Ashbolt, R., Gibbs, L., et al. (2008) Double disadvantage: the influence of ethnicity over socio-economic position on childhood overweight and obesity: findings from an inner urban population of primary school children. International Journal of Pediatric Obesity 1, 1–9. Yusuf, S., Reddy, S., Ounapuu, S., & Anand, S. (2001) Global burden of cardiovascular disease. Part I: General consideration, the epidemiological transition, risk factors and impact of urbanization. Circulation 104, 2746–2753.

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Childhood obesity—recent trends in Sweden including socioeconomic differences

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Childhood obesity—recent trends in Sweden including socioeconomic differences Elinor Sundblom Agneta Sjöberg Jennie Blank Lauren Lissner

DOI:10.1093/acprof:oso/9780199572915.003.0014

Abstract and Keywords This chapter reports on recent obesity trends among Swedish children. Sweden has a relatively low prevalence of childhood obesity. Yet, the rates in children as well as in adults have increased in the past decades. For instance, childhood overweight and obesity today are two to three times more common than in the 1980s. Moreover, a strong socioeconomic gradient has been apparent for a number of years. This chapter describes the developments of obesity and overweight in younger and older Swedish children. Where available it reports on the most recent trends, to determine whether the increase seen since the end of the 20th century has continued into the 21st century. When socioeconomic gradients are available it analyses if the gap is widening or narrowing. Finally, the chapter examines selected changes that have occurred in Swedish society that might explain the latest trends.

Keywords: overweight, obesity, children, adolescents, epidemiology, Swedish society, Sweden, SES, socioeconomic gradient, social class

Chapter summary The purpose of this chapter is to report on recent obesity trends among Swedish children. Sweden has a relatively low prevalence of childhood obesity (Haug et al., 2009; Lobstein & Frelut, 2003). Yet, the rates in children as well as in adults have increased in the past decades (Mårild et al., 2004; Petersen et al., 2003; Rasmussen & Johansson, 2000). For instance, childhood overweight and obesity today are 2–3 times more common than in the 1980s. Moreover, a strong socioeconomic gradient has been apparent for a number of years. In this

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Childhood obesity—recent trends in Sweden including socioeconomic differences

chapter, we will describe the developments of obesity and overweight in younger and older Swedish children. Where available we will report on the most recent trends, to determine whether the increase seen since the end of the 20th century has continued into the 21st century. When socioeconomic gradients are available, we will attempt to determine if the gap is widening or narrowing. Finally we will examine selected changes that have occurred in Swedish society that might explain the latest trends.

Methods and populations studied Although there are presently no nationally representative data on childhood obesity in Sweden, secular trends have been documented within school health care setting in various regions (Fig. 14.1). During their fourth year of primary school at ages 10 to 11, most children in Sweden are examined by school nurses. From such samples of Swedish 10–11-year-olds there have been three international publications since 2008 based on data extracted manually or electronically from school health records reporting on recent developments in weight status among Swedish fourth graders. Children under the age of 7 years are almost all regularly examined in child health care centres based on which BMI data for 4-year-olds in different areas of Sweden are also available (Bråbäck et al., 2009). In all studies reported in this chapter, children were classified as normal weight, overweight, (including obese) or obese using BMI according to the International Obesity Task Force (IOTF) (Cole et al., 2000). In two of these publications trends in underweight are also reported (Sjöberg et al., 2008; Sundblom et al., 2008) based on Swedish reference data where individual BMI standard deviation scores (BMI SDS) were derived and calculated from a 1974 birth cohort. Underweight was defined as 〈−2SD (Karlberg et al., 2001). Recently, Cole and co-authors suggested cut-offs for thinness based on the same international reference data as used for the overweight and obesity cut-offs (Cole et al., 2007). We have recalculated the prevalences for thinness (p.165)

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Childhood obesity—recent trends in Sweden including socioeconomic differences

for 10- to 11-year-olds in Stockholm and Gothenburg (Lissner et al., 2009) and for 4year-olds in Skaraborg, according to the suggestion of Cole et al.

Results from Swedish studies Overweight and obesity among 10-year-olds in Stockholm In Stockholm County (approximately 1.9 million inhabitants), 4599 10–11-year-old schoolchildren were sampled from different socioeconomic districts in 1999/2000 or 2003/2004 (Sundblom et al., 2008). The socioeconomic districts were divided into 322 different neighbourhood areas of varying levels of affluence according to the social atlas of Stockholm County (Inregia, 2000). These areas were aggregated into eight groups based on income level of the adult population in 1997. The eight areas were merged into pairs and results are Fig. 14.1 Map over Sweden with localization presented for four SES groupings (low, of studied populations. medium–low, medium–high, and high). Prevalence and confidence intervals were calculated after weighting to reflect the actual socioeconomic distribution in Stockholm County. About 30% of the selected schools did not permit data collection, the main reason being heavy workload among the school nurses. Participation was similarly distributed in the four SES areas with 70% of the schools in low-income areas and 70% of high-income schools agreeing to contribute data. Although this study did not detect any statistically significant changes in obesity or overweight in children from Stockholm, some interesting trends were observed, as shown in Table 14.1. From 1999–2003 overweight among girls decreased from 22.1 to 19.2% and obesity decreased from 4.4 to 2.8% (both n.s.). Among boys, the prevalence of overweight was 21.6% and 20.5% in the respective years, whereas obesity increased from 3.2 to 3.8% (both n.s.). The opposing secular changes in obesity observed in Stockholm among boys versus girls tended to differ (p = 0.051 for interaction by gender). Overweight and obesity among 10-year-olds in Gothenburg In Gothenburg, 8876 records were available for fourth graders examined in academic years starting 2000 or 2004, representing over 80% of all fourth graders in Gothenburg in a given year (Sjöberg (p.166) Table 14.1 Time trends in prevalence of overweight plus obesity (Ow + Ob), obesity (Ob), underweight (Uw), and thinness (Th) in fourth graders from six Swedish cities, according to calendar year of academic year start

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Childhood obesity—recent trends in Sweden including socioeconomic differences

Girls City

Stockholm

Gothenburg

Year

1999

2003

2000

2004

n

1187

1132

2381

2059

Ow + Ob % (95% CI) 21.6 (19.2–24.0) 20.5 (18.0–23.5) 17.1 (15.6–18.6) 17.6 (16.0–19.3) Ob% (95% CI)

3.2 (2.1–4.2)

3.8 (2.6–5.0)

2.9 (2.2–3.6)

2.8 (2.1–3.6)

Uw% (95% CI)

2.4 (1.5–3.4)

1.5 (0.8–2.3)

2.5 (1.9–3.2)

3.3 (2.5–4.1)

Th% (95% CI)

5.3 (4.0–6.6)

4.8 (3.6–6.0)

8.1 (7.0–9.2)

9.0 (7.8–10.2)

Girls City

Stockholm

Gothenburg

Year

1999

2003

2000

2004

n

1229

1051

2302

2134

Ow+Ob % (95% CI)

22.1 (19.7–24.4) 19.2 (16.7–21.7) 19.6 (17.9–21.2) 15.9 (14.4–17.6) **

Ob % (95% CI)

4.4 (3.2–5.5)

2.8 (1.7–3.8)

3.0 (2.3–3.8)

2.5 (1.9–3.2)

Uw % (95% CI)

1.7 (1.0–2.5)

1.4 (0.6–2.1)

2.2 (1.7–2.9)

2.5 (1.9–3.2)

Th % (95% CI)

7.6 (6.1–9.1)

6.0 (4.6–7.4)

9.5 (8.3–10.7)

11.9 (10.5–13.2)*

Boys and girls # City

Karlstad

Umeå

Year

2004

2005

2004

2005

n

838

799

656

818

Ow + Ob % (95% CI) 17.8 (15.2–20.4) 19.9 (17.1–22.7) 20.6 (17.5–23.7) 20.8 (18.0–23.6) Ob % (95% CI)

2.7 (1.6–3.9)

2.4 (1.3–3.4)

2.3 (1.1–3.4)

2.7 (1.6–3.8)

City

Västerås

Year

2003

2005

2003

2005

n

1131

1248

330

254

Ystad

Ow + Ob % (95% CI) 23.3 (20.9–25.8) 24.1 (21.8–26.5) 23.3 (18.8–27.9) 20.5 (15.5–25.4) Ob % (95% CI)

5.3 (4.0–6.6)

4.7 (3.6–5.9)

4.8 (2.5–7.2)

4.7 (2.1–7.3)

*Significant decrease over time, p〈0.05 **p〈0.01, all other changes non-significant. # Gender-specific rates not reported, differing observation periods by city. et al., 2008). In 2000/2001, 2302 girls and 2381 boys and in 2004/2005, 2134 girls and 2059 boys were included. Gothenburg is divided into 21 administrative areas, each with an average total population of about 20,000 inhabitants. A socioeconomic area index for each administrative area was constructed and these areas were then ranked and divided into four SES areas, each consisting of four to seven administrative areas. As shown in Table 14.1, the prevalence of overweight in girls decreased from 19.6 to 15.9% (p 〈0.01) whereas obesity decreased from 3.0 to 2.5% (n.s.). There were non-significant changes in boys: 17.1 to 17.6% overweight and 2.9 to

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Childhood obesity—recent trends in Sweden including socioeconomic differences

2.8% obese. Compared to an earlier Gothenburg cohort examined in 1984 (Karlberg et al., 2001), 2-fold increases in (p.167) overweight and 3–4-fold increases in obesity have been observed in 1999 and 2004 surveys (Mårild et al., 2004, Sjöberg et al., 2008). More recent data on fourth graders in Gothenburg during the academic year 2007–2008 revealed overweight prevalence of 12% in boys and 13% in girls; for obesity the corresponding figures were 4 and 3% respectively, suggesting stability in both sexes (Renman et al., 2009). Overweight and obesity among 10-year-olds in other parts of Sweden With the objective to test the feasibility of a system for monitoring overweight and obesity using electronic health records in schools, the Swedish National Institute of Public Health obtained school examination data from four municipalities. In Västerås and Ystad, data from 4473 10year-olds were abstracted in 2003/2004, 2004/2005, and 2005/2006 (Lager et al., 2009). Additionally, 3111 10-year-olds from Umeå and Karlstad were included in the estimates for the second and third annual cycles of the survey (academic years starting 2004 and 2005). These municipalities all used electronic health records from which data on height, weight, sex, and age were extracted yearly. Because of this new methodology only two cities could be included in the initial year, and total coverage varied between 66% and 99%. In boys and girls combined from Karlstad, Umeå, Västerås, and Ystad, the overall rates of overweight and obesity in 2005/2006 were 21.5 and 4.4% respectively, and as shown in Table 14.1, there was no convincing evidence of trends in either direction since previous years (Lager et al., 2009). Only Västerås and Ystad were included in the first (2003) estimates; in these two areas there were no significant 3-year changes in either obesity or overweight, in girls and boys combined. Socioeconomic gradients in 10-year-old children The two studies from Stockholm and Gothenburg also reported on socioeconomic gradients where trends were assessed at the residential area level (Sjöberg et al., 2008; Sundblom et al., 2008). In Sweden, most children go to school in the area where they live, and the socioeconomic status of the area can be used as an indicator of living conditions. Despite the fact that the Nordic countries are generally viewed as egalitarian, these studies confirm that obesity and overweight are more common in children from less advantaged socioeconomic environments. Among girls in both cities, decreasing trends over time were consistent in all socioeconomic groups. However, the picture in boys was less clear: in Stockholm the gap in obesity between boys from lower and higher socioeconomic groups appeared to be widening between 1999 and 2003 (Sundblom et al., 2008). In Gothenburg, increases in overweight tended to occur in boys from middle-income areas, in contrast to decreasing trends in the high- and low-income areas (Sjöberg et al., 2008). Overweight and obesity among 4-year-olds Child health care in Sweden offers a series of free health visits from birth to the age of 6 years for children and their parents. In 2004 the Stockholm County Council adopted an action programme to address overweight and obesity with preventive efforts directed at children of the highest priority (Stockholms Läns Landsting, 2009). As part of this action programme, BMI of all 4-year-old children has been recorded since 2005. In the last year, the variations in overweight and obesity have been striking between areas of different socioeconomic conditions. In more

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Childhood obesity—recent trends in Sweden including socioeconomic differences

affluent areas, around 6% of the children are overweight compared to 19% in less advantaged areas. When comparing data from previous years, it seems that the prevalence has been levelling off (Table 14.2) (Årsrapport barnhälsovården, 2008). (p.168)

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Childhood obesity—recent trends in Sweden including socioeconomic differences

Table 14.2 Prevalence of overweight plus obesity (Ow + Ob) and obesity (Ob) in 4-year-olds in the counties of Stockholm, Västerbotten, and Skaraborg County

Year

Stockholm

Västerbotten

Skaraborg

Girls

Boys

n

Ow + ob %

Ob %

n

Ow + ob %

Ob %

2004#

4246

13.2

3.0

4636

10.2

2.5

2005

9078

12.6

2.6

9 608

8.7

1.9

2006

9554

11.1

2.4

10 278

7.5

1.9

2007

9932

10.5

2.3

10 857

8.2

1.8

2002

2176

22.3

5.7

2231

17.2

3.1

2007

2156

19.0**

3.1***

2225

14.2**

2.3ns

2006

1173

18.4

3.7

1218

13.5

2.5

#Including only the northern part of Stockholm County.** p〈0.01.*** p〈0.001 chi-squared test. Difference between boys and girls.

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Childhood obesity—recent trends in Sweden including socioeconomic differences

Data on 4-year-olds in Stockholm may be compared to similar data from Western and Northern Sweden. As part of The Skaraborg Evaluation of Child Obesity Prevention Project (SECOPP), weight and height data were collected by registered nurses for all 4-year-old children visiting a Child Health Centre in Skaraborg, Western Sweden, in 2006. In these children, prevalence of overweight and obesity was substantially higher compared to that in Stockholm. In 2006, 18.4% of the girls were overweight and 3.7% were obese. For boys in Skaraborg, the corresponding figures were 13.5 and 2.5%, respectively. These figures are based on BMI cut-off points for overweight and obesity as proposed by the International Obesity Task Force (Cole et al., 2000). Additionally, local (Swedish) references were used to estimate prevalence of overweight and obesity in the same children, which in some cases differed notably from international definitions. While using the system by Karlberg, only 4.8% of the girls were overweight and 0.9% were obese. For boys the prevalences were 4.0 and 1.1% respectively. A recent study from the county of Västerbotten in the north of Sweden was published also showing decreasing prevalences in 4-year-old children. During the years 2007/2008, 2225 boys and 2156 girls were measured and compared with height and weight data from 2231 boys and 2176 girls in 2002/2003. Over the 5-year period, overweight prevalences decreased both in boys and girls (Table 14.2). Among girls there was also a decrease in obesity prevalence from 5.7 to 3.1% (Bergström & Blomquist, 2009). Finally, data on 4-year-olds from other parts of Sweden (not shown) confirms the trend seen in Stockholm County; those cohorts born after 2000 do not indicate increases in overweight (Bråbäck et al., 2009). Prevalence of underweight and thinness Since there was a stabilized prevalence and even signs of decreases in prevalence of overweight and obesity in girls in two of the studies (Sjöberg et al., 2008; Sundblom et al., 2008), it was of particular interest to also evaluate the trends in prevalence of underweight and thinness. Among Gothenburg girls, a significant increase in thinness was observed (p 〈0.05), but no significant differences were observed in boys. These rates are shown in Table 14.1. In the original publications, a Swedish standard was used for defining underweight (Karlberg et al., 2001). According to this local standard, rates of underweight were much lower in both sexes and no significant trends were seen in either city. In the Skaraborg dataset including 4-year-olds at one time point only, thinness was analysed using cut-off points according to Cole (Cole et al., 2007) and prevalence was 6.1% (p.169) in girls and 6.7% in boys. However using local definitions described in methods (Karlberg) the prevalence of underweight was 2.1 and 2.5% in the same children (data not shown).

Discussion Studies on overweight and obesity among 10- and 4-year-old children in Sweden suggest that the epidemic of childhood obesity may have reached a plateau. Among other age groups within Sweden a study in 16-year-olds has also found no evidence of increase (Ekblom et al., 2009). In summary, the studies present a picture of stabilizing obesity rates across Sweden with some gender differences and a persistent and strong socioeconomic gradient. Several studies from different parts of the world have reported similar lack of trends (Lioret et al., 2009; Mitchell et al., 2007; Ogden et al., 2008). Future surveillance is urgently needed to reveal whether the apparent plateau worldwide is temporary or not.

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Childhood obesity—recent trends in Sweden including socioeconomic differences

The gender differences observed in two of the Swedish studies on 10-year-old children (Sjöberg et al., 2008; Sundblom et al., 2008) may be interpreted in light of previous reports, in which body dissatisfaction, weight, and shape concerns are more common among girls than boys, and that these differences emerge somewhere between the ages 8–10 years (Ricciardelli & McCabe, 2001). Gender differences may be a consequence of differential reception of the health messages from school, family, media, etc., and may interact with SES, weight, and age. In a study from Australia, overweight boys, and particularly those from lower SES groups, were not as concerned about being ‘big’ as the overweight boys of higher social classes (O'Dea & Caputi, 2001). Boys may be more resistant to sociocultural influences affecting body image in contrast to girls who seem to be picking up messages on the thin body type ideal, although there is growing recognition that weight and shape concerns are not gender bound (Paxton et al., 2006). A recent Swedish study indicated that the strong prejudice against obesity among 10year-olds was influenced by gender as well as socioeconomic status (Hansson et al., 2009). Several limitations of the existing data in Sweden should also be noted. As the studies are conducted by the schools and child health centres, there is no standardization of equipment and some differences in measurement routines, for example, amount of clothing when measuring the children, can vary (Bråbäck et al., 2009). In two of the studies on 10-year-olds included in this review, certain quality checks were performed, mainly uniform use of digital scales and calibration of stadiometers (Lager et al., 2009; Sjöberg et al., 2008). In order to ensure that regional comparisons are valid, standardization of measurement equipment and methodologies is required. Additionally, given the absence of nationally representative Swedish data of childhood obesity we have to rely on regional data. The regional differences reported in the studies of 4-year-olds are apparent. For example the County Council of Stockholm had a low prevalence of overweight and obesity in 4-year-olds compared to many other Swedish regions (Bråbäck et al., 2009). Earlier studies among the adult population in Sweden has also shown that overweight and obesity are more common in rural areas and in individuals with low socioeconomic position (Kark & Rasmussen, 2005; Lissner et al., 2000). Among the adult population prevalence on a national level is stable (Socialstyrelsen, 2009) but here we can see regional differences, where in Stockholm County, the prevalences among 18–65 increased between 2002 and 2007 (Centrum för Folkhälsa, 2007). Finally, it should be emphasized that harmonization of methodologies and sampling procedures is needed, if valid international comparisons are to be made. In the remaining discussion, we will consider potential explanations for the recent plateau. It is of interest to consider whether population-based changes in diet and physical activity in recent years might explain the observed trends in Swedish children (Bergström & Blomquist, 2009; Lager et al., 2009; Sjöberg et al., 2008; Sundblom et al., 2008). National food consumption statistics indicate some positive changes in food habits during the same time period, which could contribute to (p.170) the observed trends in overweight and obesity. In the population as a whole, consumption of soft drinks had a large increase from 1995, which levelled out during the trend period. Consumption of sweets was quite stable, whereas that of fruit and vegetables has increased, as illustrated in Fig. 14.2 (Swedish Board of Agriculture, 2007). Regarding these dietary trends, it must also be acknowledged that changes in food consumption described here

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Childhood obesity—recent trends in Sweden including socioeconomic differences

are based on food production and disappearance data for the whole population, and we cannot infer that the trends apply to children. Regarding physical activity, according to a Swedish report from Statistics Sweden, leisure time activity patterns have become more sedentary among both boys and girls. Boys seem to be more interested in computer games and own a computer or TV more often than girls (Statistics Sweden, 2005). In contrast, several studies show recent increases in self-reported physical activity among adults, and it can be speculated that these trends may have a positive impact on children’s activity patterns (Berg et al., 2005; Lissner et al., 2008). The reasons for lifestyle changes that may have slowed the obesity in recent years are not well understood. There has been an enormous media attention to overweight, healthy food habits, and physical activity, which have resulted in a broad awareness of the problem in the society and increased awareness among parents. According to unpublished data from the National Food Administration, the number of articles in the popular press naming words ‘obesity’, ‘sugar’, or ‘overweight’ increased from a few hundreds in 2001 to nearly 10,000 in 2007 (Fig. 14.3). During this time, several local and some regional action plans were adopted and many activities have started in child health care, in pre-schools, schools, and sport clubs. Sweden has a long tradition of official nutrition recommendations, food-based dietary guidelines, free child health care, free school meals, and school health care in every school, which probably formed a solid ground for the recent activities. Swedish children are also to a certain extent protected from commercial pressures. A national ban on radio and TV advertising, targeting children under the age of 12 that prohibits advertising before, after, and during children’s programmes, was introduced in 1996. Swedish children are, however, like children in other countries, exposed to marketing through unregulated channels as well as the Internet and mobile phones, in addition to the use of new methods like viral marketing, brand ambassadors, etc. The commercial pressure on children has been the subject of considerable debate in Sweden and the majority of parents want stricter regulation, especially on the Internet (von Haartman, 2009). (p.171)

Fig. 14.2 Changes in food consumption in Sweden 1990 to 2006.

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Childhood obesity—recent trends in Sweden including socioeconomic differences

Sweden is one of the few European countries that have not launched a specific national action plan for healthy dietary habits and physical activity, although a proposal was made in 2003 to take action on many levels. Based on this proposal, the ‘79 points of action’ (National Food Administration and National Institute of Public Health, 2005) received wide media attention, but no major national level action plan was adopted. The government decided Fig. 14.3 Number of articles in Swedish that it was ‘enough’ that the country had a newspapers with the words obesity, sugar, national public health policy, which includes and overweight. diet and physical activity. A widespread debate regarding childhood obesity in 2004 raised in the media by the National Institute of Public Health’s proposal to add taxes on soft drinks and sweets provoked a strong response by manufacturers and retailers, and the following year soft drink consumption decreased (Swedish Board of Agriculture, 2007). The decreasing and stable trends in obesity are probably a sign that many regional and local actions have taken place in different sectors and levels as a result of the societal debate about these issues. Unfortunately, these regional and local efforts, although they have possibly contributed to the recent plateau, have not been sufficient to decrease prevalence to levels previously observed in the 1980s or to reverse the socioeconomic gradient. To bring the childhood obesity rates down to acceptable levels and to reach the less affluent groups, concerted, multi-sectorial, long-term actions are needed in combination with a much larger political determination.

Acknowledgements This work was supported in part by the Swedish Council on Working Life and Social Research (FAS). We thank Dr. Annica Sohlström at the Swedish National Food Administration for providing data on media coverage of the obesity epidemic. References Bibliography references: Årsrapport Barnhälsovården (2008) Stockholm, Stockholms Läns Landsting. Berg, C., Rosengren, A., Aires, N., et al. (2005) Trends in overweight and obesity from 1985 to 2002 in Goteborg, West Sweden. International Journal of Obesity 29, 916–924. Bergström, E. & Blomquist, H.K. (2009) Is the prevalence of overweight and obesity declining among 4-year-old Swedish children? Acta Paediatrica 98, 1956–1958.

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Bråbäck, L., Bågenholm, G., & Ekholm, L. (2009) Fetmautvecklingen Bland Svenska 4-Åringar Tycks Ha Stannat Av. Men Stora Regionala Skillnader Visar Socioekonomins Betydelse. Läkartidningen 106, 2758–2761 (In Swedish). Centrum för Folkhälsa (2007) Folkhälsan I Stockholms Län 2007. Stockholm, Stockholms Läns Landsting. Cole, T.J., Bellizzi, M.C., Flegal, K.M., & Dietz, W.H. (2000) establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320, 1240–1243. Cole, T.J., Flegal, K.M., Nicholls, D., & Jackson, A.A. (2007) Body mass index cut offs to define thinness in children and adolescents: international survey. BMJ 335, 194. Ekblom, O.B., Bak, E.A., & Ekblom, B.T. (2009) Trends in body mass in Swedish adolescents between 2001 and 2007. Acta Paediatrica 98, 519–522. Hansson, L.M., Karnehed, N., Tynelius, P., & Rasmussen, F. (2009) Prejudice against obesity among 10-year-olds: a nationwide population-based study. Acta Paediatrica 98, 1176–1182. Haug, E., Rasmussen, M., Samdal, O., et al. (2009) Overweight in school-aged children and its relationship with demographic and lifestyle factors: results from the WHO-collaborative health behaviour in school-aged children (HBSC) study. International Journal of Public Health 54 (Suppl 2), 167–179. Inregia (2000) Social Atlas Över Stockholmsregionen (Social Atlas). Stockholm, Regionplane – Och Trafikkontoret. Stockholm County Council. Kark, M. & Rasmussen, F. (2005) Growing social inequalities in the occurrence of overweight and obesity among young men in Sweden. Scandinavian Journal of Public Health 33, 472–477. Karlberg, J., Luo, Z.C., & Albertsson-Wikland, K. (2001) Body mass index reference values (mean and SD) for Swedish children. Acta Paediatrica 90, 1427–1434. Lager, A.C., Fossum, B., Rörvall, G., & Bremberg, S.G. (2009) Children's overweight and obesity: local and national monitoring using electronic health records. Scandinavian Journal of Public Health 37, 201–205. Lioret, S., Touvier, M., Dubuisson, C., et al. (2009) Trends in child overweight rates and energy intake in France from 1999 to 2007: relationships with socioeconomic status. Obesity (Silver Spring) 17, 1092–1100. Lissner, L., Johansson, S.E., Qvist, J., Rössner, S., & Wolk, A. (2000) Social mapping of the obesity epidemic in Sweden. International Journal of Obesity 24, 801–805. Lissner, L., Sjöberg, A., Schutze, M., Lapidus, L., Hulthen, L., & Björkelund, C. (2008) Diet, obesity and obesogenic trends in two generations of Swedish women. European Journal of Nutrition 47, 424–431.

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Lissner, L., Sohlström, A., Sundblom, E., & Sjöberg, A. (2009) Trends in overweight and obesity in Swedish schoolchildren 1995–2005 – has the epidemic reached a plateau? Obesity Reviews. [Epub ahead of print]. Lobstein, T. & Frelut, M.L. (2003) Prevalence of overweight among children in Europe. Obesity Reviews 4, 195–200. Mitchell, R.T., Mcdougall, C.M., & Crum, J.E. (2007) Decreasing prevalence of obesity in primary schoolchildren. Archives of Diseases in Childhood 92, 153–154. Mårild, S., Bondestam, M., Bergström, R., Ehnberg, S., Hollsing, A., & Albertsson-Wikland, K. (2004) Prevalence trends of obesity and overweight among 10-year-old children in Western Sweden and relationship with parental body mass index. Acta Paediatrica 93, 1588–1595. National Food Administration and National Institute of Public Health (2005) Background material to the action plan for healthy dietary habits and increased physical activity – the basis for an action plan. O'dea, J.A. & Caputi, P. (2001) Association between socioeconomic status, weight, age and gender, and the body image and weight control practices of 6- to 19-year-old children and adolescents. Health Education Research 16, 521–532. Ogden, C.L., Carroll, M.D., & Flegal, K.M. (2008) High body mass index for age among US children and adolescents, 2003–2006. JAMA: the Journal of the American Medical Association 299, 2401–2405. Paxton, S.J., Eisenberg, M.E., & Neumark-Sztainer, D. (2006) Prospective predictors of body dissatisfaction in adolescent girls and boys: a five-year longitudinal study. Developmental Psychology 42, 888–899. Petersen, S., Brulin, C., & Bergstrom, E. (2003) Increasing prevalence of overweight in young schoolchildren in Umea, Sweden, from 1986 to 2001. Acta Paediatrica 92, 848–853. Rasmussen, F. & Johansson, M. (2000) Increase in the prevalence of overweight and obesity from 1995 to 1998 among 18-year-old males in Sweden. Acta Paediatrica 89, 888–889. Renman, C., Nordström, M., & Mangelus, L. (2009) Sammanställning Av Årsredogörelser 2008 För Skolhälsovården I Göteborg. Göteborgs Stad, Skolhälsan February 2009. Ricciardelli, L.A. & Mccabe, M.P. (2001) Children's body image concerns and eating disturbance: a review of the literature. Clinical Psychology Reviews 21, 325–344. Sjöberg, A., Lissner, L., Albertsson-Wikland, K., & Mårild, S. (2008) Recent anthropometric trends among Swedish school children: evidence for decreasing prevalence of overweight in girls. Acta Paediatrica 97, 118–123. Socialstyrelsen (2009) Folkhälsorapport 2009. Västerås.

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Statistics Sweden (2005) Barns Villkor (Living conditions of children and youth). . Stockholms Läns Landsting (2009) Handlingsprogram Övervikt Och Fetma. Stockholm. Sundblom, E., Petzold, M., Rasmussen, F., Callmer, E., & Lissner, L. (2008) Childhood overweight and obesity prevalences levelling off in Stockholm but socioeconomic differences persist. International Journal of Obesity 32, 1525–1530. Swedish Board of Agriculture (2007) Konsumtionen Av Livsmedel Och Dess Näringsinnehåll. Von Haartman, F. (2009) Stakeholders views on policy options for marketing food and beverages to children. findings from the Polmark Project in Sweden. 2009:9. Stockholm, Karolinska Institutets Folkhälsoakademi.

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Childhood obesity in the Middle Eastern countries with special reference to Iran

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Childhood obesity in the Middle Eastern countries with special reference to Iran Kelishadi Roya

DOI:10.1093/acprof:oso/9780199572915.003.0015

Abstract and Keywords In the last two decades, obesity rates have increased in developing countries experiencing a rapid epidemiologic transition, especially in terms of adopting a Western lifestyle involving decreased physical activity and overconsumption of cheap, energy-dense food. The Middle East, Pacific Islands, Southeast Asia, and China appear to face the greatest threat. This growing health problem is also affecting the children of these countries, with a paradox of concurrent childhood underweight/obesity existing in many of these countries. Childhood obesity is also developing in the Middle Eastern countries, largely in response to social and economic changes. The differences between the age groups reported in this chapter, the subjects' living area (urban/rural) as well as the BMI cut-offs used make the comparisons difficult. In general, Middle Eastern studies show that the prevalence of childhood obesity in Iran is lower than Arab countries in the region and some parts of Turkey; this may be due to both genetic and lifestyle differences between Iranian and Arab nations. Until few years ago, childhood under-nutrition has been the major nutritional problem in many Middle-Eastern countries, and still it is the focus of nutritional policies and related medical education curriculum. However, the higher prevalence of overweight than underweight obtained in aforementioned surveys is alarming, and confirms the importance of considering childhood overweight as a health priority. This should be taken into account for all Middle Eastern countries that are expected to bear one of the world's greatest increases in the burden of chronic diseases, notably diabetes and cardiovascular diseases, in the next two decades. Given that the Middle Eastern populations are facing the world's greatest increment in the absolute burden of future diabetes, preventive measures should be considered from early life.

Keywords: children, adolescents, epidemiology, comparison, Iran, Middle East, social class, income, socioeconomic status, SES

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Childhood obesity in the Middle Eastern countries with special reference to Iran

Chapter summary In the last two decades, the rates of obesity have increased in developing countries experiencing a rapid epidemiologic transition especially in terms of adopting a Western lifestyle involving decreased physical activity and overconsumption of cheap, energy-dense food. The Middle East, Pacific Islands, Southeast Asia, and China appear to face the greatest threat. This growing health problem is also affecting the children of these countries, with a paradox of concurrent childhood underweight/obesity existing in many of these countries. Childhood obesity is also developing in the Middle Eastern countries, largely in response to social and economic changes. The differences between the age groups reported in this chapter, the subjects’ living area (urban/rural), as well as the BMI cut-offs used make the comparisons difficult. In general, these Middle Eastern studies show that the prevalence of childhood obesity in Iran is lower than Arab countries in the region and some parts of Turkey; this is suggested to be due to both genetic and lifestyle differences between Iranian and Arab nations. Until a few years ago, childhood undernutrition had been the major nutritional problem in many Middle-Eastern countries, and still is the focus of nutritional policies and related medical education curriculum; however, the higher prevalence of overweight than underweight obtained in aforementioned surveys is alarming, and confirms the importance of considering childhood overweight as am health priority. This should be taken into account for all Middle Eastern countries that are expected to bear one of the world's greatest increases in the burden of chronic diseases, notably diabetes and cardiovascular diseases, in the next two decades. Given that the Middle Eastern populations are facing the world's greatest increment in the absolute burden of future diabetes (Wild et al., 2004), preventive measures should be considered from early life. In this chapter, we present a general overview of the prevalence of childhood overweight and obesity in the Middle Eastern countries while focusing on the situation in Iran.

Introduction The relationship between obesity and socioeconomic characteristics of different populations is complex. The changes in dietary and activity patterns are occurring at great speed and at earlier stages of the economic and social development of each country (Popkin & Gordon-Larsen, 2004), and there is an escalating shift in the burden of poor diets, inactivity, and obesity from the rich to the poor populations (Popkin, 2004). However, as stated by Hossain et al. (2007), being poor in one of the world's poorest countries (i.e., in countries with a per capita gross national product (GNP) of less than $800 per year) is associated with underweight and malnutrition, whereas being poor in a middle-income country (with a per capita GNP of about $3,000 per year) is associated with an increased risk of obesity (Hossain et al., 2007). It is worth mentioning that the co-existence of overweight/obesity and stunting is an important public health issue in children of low- and (p.175)

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Childhood obesity in the Middle Eastern countries with special reference to Iran

middle-income countries. Maternal malnutrition and the associated intrauterine growth retardation in a thrifty genotype background, along with compromised breast feeding and improper infant feeding may also lead to stunting in early life. The mistaken behaviors of families in overfeeding of stunted children will result to rapid weight gain and high fat mass accompanied by a central fat deposition later in childhood and adolescence (Hossain et al., 2007; Kelishadi, 2007). Of special concern in this regard is the situation of the Middle Eastern countries with the highest dietary energy surplus among the developing countries and with rapid changes in the socio-demographic characteristics of the region, large shifts in dietary and physical activity patterns, and a rapid rise in risk factors of chronic diseases

Fig. 15.1 Prevalence of childhood obesity in some Middle Eastern countries in comparison to other developing countries in Asia. Adapted with permission from Kelishadi et al. (2007). Russia, United Arab Emirates (UAE): IOTF criteria; Iran, Kuwait, Bahrain, India, China: CDC 2000; Saudi Arabia: NCHS; Sri Lanka: WHO curves for height-to-weight ratio.

especially obesity (Galal, 2003). There remains an existing belief among families that childhood obesity is a sign of health for their children (Kelishadi, 2007; Kelishadi et al., 2005). The prevalence of childhood overweight and obesity is considerably higher among Middle Eastern children than among children from other developing countries. For example, a comparison with other developing countries in Asia is presented in Fig. 15.1. The findings of studies in different Middle Eastern countries are provided in Table 15.1. Here, studies in Iran are explained in more detail. Data on the prevalence of overweight and obesity are scarce and largely different among various parts of the country. A national survey was conducted on a representative sample of 21,111 school students including 10,253 boys (48.6%) and 10,858 girls (51.4%) aged 6–18 years, from urban (84.6%) and rural (15.4%) areas of 23 provinces in Iran. The percentage of individuals in the corresponding BMI categories of the Centers of Disease Control and Prevention (CDC), the International Obesity Task Force (IOTF), and the obtained national percentiles were assessed and compared. (p.176) Table 15.1 Prevalence of overweight and obesity in children and adolescents of the Middle Eastern countries (sorted by the publication year)

Page 3 of 19

Childhood obesity in the Middle Eastern countries with special reference to Iran

Study

Country and population

Criteria

Findings

De Onis & Blössner, 2000

160 nationally representative cross-sectional surveys from 94 countries were analysed in a standardized way to allow comparisons across countries and over time.

Overweight was defined as a weightfor-height 〉2 SDs from the National Center for Health Statistics/World Health Organization international reference median. Prevalence of wasted children ( − 2 SDs) are also presented to enable comparisons.

The global prevalence of overweight was 3.3%. Some countries and regions, however, had considerably higher rates, and overweight was shown to increase in 16 of 38 countries with trend data. Countries with the highest prevalence of overweight are located mainly in the Middle East, North Africa, and Latin America. Rates of wasting were generally higher than those of overweight; Africa and Asia had wasting rates 2.5–3.5 times higher than overweight rates. Countries with high wasting rates tended to have low overweight rates and vice versa.

Musaiger et al., 2000

584 Bahraini girls aged 12–19 years.

National Health and Prevalence of overweight Nutrition Examination was 38.5% and obesity was Survey I (NHANESI) 6.3%. BMI distribution.

Dorosty et al., 2002

4315 2–5-year-olds in Iran A survey was carried out in two largely rural provinces of Iran in 1995: Gilan (population 2.2 million, literacy rate 79%) and Sistan (1.7 million, literacy 57%). The survey was designed to provide a random sample of approximately 4000 2–5-year-olds (1% of target population) attending community clinics for routine health checks.

Prevalence of obesity (BMI 〉95th centile, Iranian reference data) was compared with the recent ‘IOTF’ approach.

Page 4 of 19

Prevalence was significantly higher than expected, and increased with age, but contradictory trends were obtained from the two approaches.

Childhood obesity in the Middle Eastern countries with special reference to Iran

Study

Country and population

Criteria

Findings

Kelishadi et al., 2003

The subjects were 1000 girls and 1000 boys, aged between 11 and 18 years selected by multistage random sampling, their parents (n = 2000), and their school staff (n = 500 subjects) in urban and rural areas of two provinces in Iran.

The present study is the first phase (present situation analysis) of one of these projects, the Heart Health Promotion from Childhood (HHPC).

The prevalence of 85th percentile ≤ body mass index (BMI) 〈 95th percentile and BMI 〉 95th percentile in girls was significantly higher than boys (10.7 ± 1.1 and 2.9 ± 0.1% versus 7.4 ± 0.9 and 1.9 ± 0.1%, respectively; P 〈0.05).The mean BMI value was significantly different between urban and rural areas (25.4 ± 5.2 versus 23.2 ± 7.1 kg/m2, respectively; P 〈 0.05). A BMI 〉 85th percentile was more prevalent in families with an average income than in highincome families (9.3 ± 1.7 versus 7.2 ± 1.4%, respectively; P 〈 0.05) and in those with lower-educated mothers (9.2 ± 2.1 versus 11.5 ± 2.4 years of mother’s education respectively).

Tabatabaei et al., Using two-stage cluster sampling, a 2003 total of 3482 students aged 6–12 Y (1843 boys and 1639 girls) were randomly selected from Ahwaz, Iran, primary schools.

By using three different sets of baseline values, namely, IOTF, CDC, and local data from Iran.

Prevalence rates according to Iranian reference data, CDC 2000, and IOTF 2000 were 10.9%, 5.2%, and 3.6% respectively.

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Study

Country and population

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James, 2004

BMI data are being evaluated as part of a new analysis of the Global Burden of Disease. A standardized classification of overweight and obesity, based on the body mass index now allows a comparison of prevalence rates worldwide for the first time. In children, the International Obesity Taskforce age, sex, and BMI specific cut-off points are increasingly being used. BMI data are being evaluated as part of a new analysis of the Global Burden of Disease.

Prevalence rates for overweight and obese people are very different in each region with the Middle East, Central and Eastern Europe, and North Americans having higher prevalence rates.

Prevalence rates for overweight and obese people are very different in each region with the Middle East, Central and Eastern Europe, and North Americans having higher prevalence rates. Obesity is usually now associated with poverty even in developing countries. Relatively new data suggest that abdominal obesity in adults, with its associated enhanced morbidity, occurs particularly in those who had lower birth weights and early childhood stunting.

Oner et al., 2004

989 adolescents, aged between 12 and 17 years were collected who were living in urban and rural areas of central Edirne, Turkey, to compare the 95th percentile BMI curve to those of adolescents from other countries.

The prevalence of underweight was defined as the percentage of adolescents below the 5th percentiles of the American adolescents’ age and gender specific BMI; prevalence of overweight and obesity were based on the cut-off points of the International Obesity Task Force values (excess of the 85th and 95th percentiles), respectively.

Prevalence of underweight, overweight, and obesity among adolescent girls was 11.1%, 10.6%, and 2.1%, respectively, whereas it was 14.4%, 11.3%, and 1.6% for adolescent boys. In the urban areas, among adolescent girls it was 10.0%, 10.3%, and 2.1%, whereas it was 14.4%, 11.6%, and 1.6% for boys, respectively. In the rural areas, among adolescent girls it was 15.7%, 12.4%, and 2.2%, whereas it was 14.5%, 9.6%, and 1.2% for boys, respectively.

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Childhood obesity in the Middle Eastern countries with special reference to Iran

Study

Country and population

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Mohammadpour- This descriptive Ahranjani et al., study was conducted in 2004 Tehran city, 2000– 2001. A multistage sampling method, in which 2321 students (1068 males and 1253 females) aged 11– 16 years were assessed in Tehran, Iran.

The National Center for Health Statistics/ Centers for Disease Control and Prevention (2000) criteria.

The overall prevalence of overweight and obesity was 21.1 and 7.8%, respectively. The prevalence of overweight among girl students (i.e. 23.1%; 95% confidence interval (CI) 20.8–25.4) was significantly higher than that among boys (i.e. 18.8%; 95% CI 16.5– 21.1, P = 0.01) even after adjustment for age (odds ratio 1.26, 95% CI 1.03–1.55, P = 0.02). No significant risk of obesity associated with age was found in girls or boys. In both sexes, median values of age-specific BMI in this study were statistically higher than corresponding values collected in Tehrani adolescents 10 years ago (P = 0.03). Similarly, a significant difference was seen between girl students in this study and the reference population (P = 0.03).

Al-Haddad et al., UAE, 16,391 2005 children was drawn from 145,492 pupils.

BMIs for UAE were compared to recently published international standards, overweight (〉25 kg m−2 and ≤30 kg m−2) and obesity (≥30 kg m−2).

10-year-old male had 1.7 times the rate of overweight and 1.9 times at 18 years, females had 1.8 times the rate of overweight at 10 and 18 years of age. The rate of obesity was 2.3-fold higher among UAE males at 14 years and increased to 3.6 times at 18 years of age. Female children’s obesity was same as males at 14 years, at 2.3 times. At 18 years of age, UAE female obesity was 1.9-fold higher than the international standards, nearly one-half the rate of obesity among UAE males at the same age.

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Study

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Gargari et al., 2005

Tabriz, a sample of 1650 (final study group, 1518) highschool girls aged 14 to 20 years was selected.

BMI percentiles from the First National Health and Nutrition Examination Survey (NHANES I) and the International Obesity Task Force (IOTF) BMI cut-offs.

According to the NHANES I criteria, 14.6% of the study subjects were overweight or obese. Overweight and obesity was seen in 11.1% and 3.6% of the students, respectively. By the IOTF cut-offs, 14% of the subjects were overweight or obese. Overweight and obesity were seen in 10.1% and 3.9% of the students, respectively.

Shahidi et al., 2005

341 male adolescents aged 14–16 years were randomly selected through a cluster sampling in Tabriz high schools.

According to the NHANES-I criteria, BMI≥85 was considered as overweight/obese and BMI〈15 as underweight.

Based on NHANES-I criteria, underweight was found in 12%, overweight/obese in 20%, and abdominal obesity in 16%. There was a significant difference between the overweight/ obese and underweight subjects regarding the energy intake.

Mostafavi et al., 2005

From January 2001 to April 2002, sample population (N: 4048) aged 13– 99 years consisting of 803 adolescents (13–18 years) and 3245 adults (〉18 years)in Shiraz, Iran.

Anthropometric measurements including height and weight were taken. BMI was calculated and prevalence of obesity and over weight was determined for each sex by age groups.

2.9% of adolescents were obese and 11.3% were overweight. The prevalence of adult obesity and overweight was 11.7% and 33.3% respectively. The prevalence of obesity and overweight was significantly higher among women; obese women and men were more likely to be between 50–59 years of age and among overweight men and women, a higher percentage were in the 40– 49 year group.

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Bazhan et al., 2005

The present study was conducted between 2000–01 in high school girls, aged 14–17 years, living in Lahijan – Iran. In this descriptiveanalytical study, 400 students were selected by random stratified sampling from 12 schools.

Weight, height, waist, and hip circumferences were measured and BMI and WHR were calculated. BMIs at or above the 85th and 95th percentiles for age and sex (based on WHO standard) were classified as overweight and obese, respectively. Also, WHR of 0.8 or greater was considered as central obesity.

The prevalence of obesity and overweight were 5.3% and 14.8%, respectively. 21.5% of subjects and 66.7% of obese girls had a central pattern of fat distribution. Mean energy, carbohydrate, and fat intakes were significantly higher for overweight/obese girls than for under weight and normal weight girls (P 〈0.0001).

Prevalence of overweight and obesity was based on the international cutoff points for BMI by age and gender proposed by the International Obesity Task Force.

Prevalence of overweight and obesity was 26% and 7% respectively in boys, 25% and 6% in girls. Overweight was significantly associated with low physical activity (P 〈 0.05) and mother's BMI (P 〈 0.05).

Overweight and obesity was defined based on the 85th and 95th percentiles of body mass index for age and sex, respectively, as proposed by CDC in 2000.

The overall prevalence rates of overweight and obesity were 6.1% and 2.3%, respectively. The prevalence of overweight was 5% in high school boys and 7.1% in girls; the prevalence of obesity was 2.8% in boys and 1.8% in girls of high schools. Overweight and obesity increased with the educational levels of father and mother, working fathers, and private schools.

Jabre et al., 2005 A total of 234 children aged 6–8 years in: 131 boys, 103 girls. Prepubertal children in Beirut, Lebanon's capital.

Taheri et al., 2008

Study was performed in 2005 in Birjand, on 2230 students (1115 boys and 1115 girls), 15–18 years old.

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Study

Country and population

Hamidi et al., 2006

A total of 13,086 children aged 7–12 years were screened in Tehran, Iran; and those with waist circumference = 90th percentile of their age were invited for further evaluations.

Moayeri et al., 2006

During a multistage stratified cluster sampling, 2900 students (1200 males and 1700 females) aged 11– 17 years were selected from 20 secondary schools in the school year of 2004–2005 in Tehran, Iran.

Al-Hazzaa et al., 2007

Saudi male adolescents between 1988 and 1996.

Criteria

Findings Of 532 children (274 boys, mean age 9.5 +/− 1.3) enrolled in the study, 194 were overweight and 338 were obese. Mean levels of triglyceride and Apolipoprotein B in obese children were significantly higher than overweight participants. A total of 81.9% of obese children and 75.4% of overweight children had at least one cardiovascular risk factor.

Using reference growth charts from the National Centre for Health Statistics (NCHS)/ Centres for Disease Control and Prevention (CDC) (2000).

Prevalence of overweight and obesity were 17.9 and 7.1%, respectively. BMI increased with age, and it was higher in those who had lower levels of physical activity. Age at menarche was negatively associated with BMI. There was no relationship between macroand micronutrient intake and overweight and obesity. BMI of Saudi adolescents progressively increased at both 50(th) and 90(th) percentiles between 1988 and 1996. The increases in BMI during the 8-year period ranged from 9.6 to 10.8% at the 50(th) percentiles and from 10.9 to 13.9% at the 90th percentiles. At ages 15–18 years, the yearly increase in median BMI from 1988 to 1996 averaged 0.246 kg/m.

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Study

Country and population

Criteria

Findings

Malik & Bakir, 2007

In the United Arab Emirates (UAE). Secondary analysis was undertaken of data on 4381 children aged 5–17 years from the 1999 UAE-National Iodine Deficiency Surveillance Study.

The prevalence of overweight and obesity was estimated using International Obesity Task Force criteria.

Overall, 944 (21.5%) of children were overweight and 601 (13.7%) of these were obese. More girls than boys were overweight (22.9% versus 20.2%; P ≤ 0.001). Non-citizen girls were more likely to be obese (odds ratios [OR] 1.767, 95% confidence intervals [CI] 1.48–2.102) than UAE girls. Boys in the rural areas had the lowest prevalence (23.6%) and were the least likely of all the children to be either overweight or obese.

Kelishadi et al., 2007,2008

This crosssectional national survey was conducted on a representative sample of 21,111 school students including 10,253 boys (48.6%) and 10,858 girls (51.4%) aged 6–18 years, selected by multistage random cluster sampling from urban (84.6%) and rural (15.4%) areas of 23 provinces in Iran.

The percentage of subjects in the corresponding body mass index (BMI) categories of the Centres of Disease Control and Prevention (CDC), the International Obesity Task Force (IOTF) and the obtained national percentiles were assessed and compared.

There was no gender difference in BMI, but was higher in boys living in urban than in rural areas (18.4±3.88 versus 17.86±3.66 kg/m2 respectively, P 〈 0.05). The prevalence of underweight was 13.9% (8.1% of boys and 5.7% of girls) according to the CDC percentiles, and 5% (2.6% of boys and 2.4% of girls) according to the obtained percentiles. According to the CDC, IOTF, and national cutoffs, the prevalence of overweight was 8.82%, 11.3%, and 10.1% respectively; and the prevalence of obesity was 4.5%, 2.9%, and 4.79% respectively. The prevalence of overweight was highest (10.98%) in the 12-year-old group and that of obesity (7.81%) in the 6year-old group.

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Childhood obesity in the Middle Eastern countries with special reference to Iran

Study

Country and population

Criteria

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Maddah, 2008

Rasht city, northern Iran, Data on 1465 overweight/obese children and adolescents aged 2–18 years engaged in weight loss programme were analysed in this study.

These data included age, sex, weight, height, self-reported parental weight and height, history of dieting, and mother's level of education.

There were more overweight/obese girls engaged in weight loss programme than overweight/obese boys (71.2% versus 28.8% pb0.0001). These data showed that only 18.2% of the overweight/obese children and adolescents were from families with low maternal education.

Height and weight were measured and BMI calculated. Obesity was defined as having a BMI ≥95th percentile of Iranian reference or CDC. Also, the students with BMI greater than IOTF values were identified as obese.

The prevalence of obesity according to the Iranian reference, CDC and IOTF were 8.5 % (CI 95%, 7.1– 10.0%), 4.6% (CI 95%, 3.5– 6.0%), and 7.3 % (CI 95%, 6.0–9.0%), respectively. Using CDC reference, a significant difference in prevalence of obesity between girls and boys (5.8% versus 3.1%) was found (p 〈0.05). When the Iranian reference was applied, the prevalence of obesity was shown to be significantly higher in boys aged 7 and 8 compared to girls (15.2% versus 6.4% and 12.5% versus 4.0%) respectively (p 〈0.05). Finally, the application of IOTF reference produced no significant difference in prevalence of obesity between girls and boys.

Baygi et al., 2008 Assessment of the prevalence of obesity among school children in Neishabour using several references, CDC 2000 and IOTF 2000. 1471 students aged 6–12 were selected by two-stage cluster sampling.

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Study

Criteria

Findings

Amin et al., 2008 A cross-sectional descriptive study including 1139 Saudi males enrolled in the fifth and sixth grades in public primary schools in Al Hassa, KSA, through a multistage random sampling technique.

Interview using Youth and Adolescent Food Frequency Questionnaire, gathering data regarding dietary intake, some dietary habits, followed by anthropometric measurements with calculation of body mass index, the interpretation of which was based on using Cole's tables for standard definition of overweight and obesity. Sociodemographics data were collected through parental questionnaire form.

The prevalence of overweight among the included subjects was 14.2% whereas obesity was 9.7%, more in urban, older age students; mothers of obese and overweight were less educated, more working. Missing and/or infrequent intake of breakfast at home, frequent consumption of fast foods, low servings of fruits, vegetables, milk, and dairy product per day, with frequent consumption of sweets/candy and carbonated drinks were all predictors of obesity and overweight among the included male schoolchildren.

A total of 9312 school children aged 6–17 years in Rasht, northern Iran, were studied.

Data on age, skipping breakfast, physical activity, parental and educational levels were collected. Parental current body weight, height, age, current medications and being diabetic were self-reported.

The overall prevalence of overweight and obesity in these school children was 14.5% and 5.6%, respectively. Overweight and obesity was more prevalent among children living in diabetic families than nondiabetic families (22.0% versus14.0% Pb0.0001). Results of logistic regression analysis showed that risk of overweight was higher in children and adolescents whose either parent was diabetic OR = 2.02 (1.5–2.6) after controlling for other variables including maternal educational levels, parental obesity, and skipping breakfast.

Maddah, 2009a

Country and population

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Childhood obesity in the Middle Eastern countries with special reference to Iran

Study

Country and population

Criteria

Findings

Maddah, 2009b

Rural areas in Guilan province in 2006. A multistage sampling method was used and 1036 randomly selected school girls were studied in rural areas in Guilan, Iran.

Data on age and mother's years of schooling were collected using questionnaire and body weight and height were measured.

The overall prevalence of overweight and obesity in this population was 18.6% and 5.2%, respectively. Results of logistic regression analysis showed that the risk of overweight was higher in the lower age group (OR = 2.5, 95% CI 0.16–3.3). In this study, overweight was more common in girls with more educated mothers than the girls with less educated mothers (30.0% versus 20.3% P = 0.0001).

Discigil et al., 2009

A total of 924 children and 424 adolescents were screened for obesity. The age range of 6–16 years was designed as a crosssectional, population-based study. Sample of primary school children in Aydin, Turkey, was randomly selected.

Centres for Disease Control 2000 growth charts for children and adolescents were used to identify BMI percentiles. Weight and height percentiles were obtained from charts of growth curves for Turkish children.

Overweight and obesity prevalence in primary school children living in Aydin was 12.2% and 3.7%, respectively. High socioeconomic status was found to be associated with childhood obesity. There was no association between obesity and gender, adolescence, educational status of parents, and occupation of father.

(p.177) (p.178) (p.179) (p.180) (p.181) (p.182) There was no gender difference in BMI, but BMI was higher in boys living in urban than in rural areas (18.4 + 3.88 versus 17.86 + 3.66 kg/m2, respectively). According to the CDC, IOTF, and national cut-offs, the prevalence of overweight was 8.8%, 11.3%, and 10.1% respectively; and the prevalence of obesity was 4.5%, 2.9%, and 4.8% respectively. Significant differences were found between various counties, based on the CDC cut-off values. The lowest prevalence of these weight disorders was documented in Zahedan, in the south-east (3.1% overweight and 0.6% obesity), and Shahrekord in the central part of the country (6.2% overweight and 2.3% obesity), respectively, and the highest prevalence being in Rasht, the northern part (18.8% overweight and 7.4% obesity) and Qom, the central part (18.4% overweight and 7.3% obesity), respectively. The prevalence of overweight was highest (11.0%) in the 12-year-old group and that of obesity (7.8%) in the 6-year-old group. The kappa correlation coefficient was 0.71 between the CDC and IOTF criteria, 0.64 between IOTF and national cut-offs, and 0.77 between CDC and national cutoffs (Kelishadi et al., 2007, Kelishadi et al., 2008).

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Childhood obesity in the Middle Eastern countries with special reference to Iran

The national screening survey of 899,035 children (48.8% girls and 51.2% boys) at school entry that was conducted in all 31 provinces of Iran in 2007 showed that based on the CDC cut-off points, 12.7% of children had a BMI below the age- and gender-specific 5th percentile, with the highest prevalence in the southern provinces. In addition, 17% of the children had high BMI levels, i.e., 13.5% were overweight and 3.5% were obese, with the highest prevalence in the capital city as well as in the western and north-western provinces ( Fig. 15.2). (p.183) Other studies have been conducted locally in some cities of the country. A study among 2900 students (1200 males and 1700 females) aged 11–17 years in Tehran, the capital city, documented a prevalence of 17.9 and 7.1% for overweight and obesity, respectively. BMI increased with age, and it was higher in those who had lower levels of physical activity (Moayeri et al., 2006). In a study in Tabriz (north-west Iran), 1518 high school girls aged 14 to 20 years selected by stepwise random sampling from five districts were studied. Overweight and Fig. 15.2 Prevalence of body mass index 〉 obesity were defined according to body 85th percentile (categorized to less than mass index (BMI) percentiles from the First 10%, 10–20%, and 〉 20%) in 6-year-old National Health and Nutrition Examination children at elementary school entry (n = 899,035) in different provinces of Iran, 2007 Survey (NHANES I) and the International (Ziaoddini et al., 2010). Obesity Task Force (IOTF) BMI cut-offs. According to the NHANES I criteria, 14.6% of the study subjects were overweight or obese. Overweight and obesity were seen in 11.1% and 3.6% of the students, respectively. By the IOTF cut-offs, 14% of the subjects were overweight or obese. Overweight and obesity were seen in 10.1% and 3.9% of the students, respectively. Of the study subjects, 8% had a BMI below the 15th percentile of NHANES I, an indicator of underweight. The prevalence of overweight and obesity in Tabriz high-school girls is higher than in many, but not all, parts of Iran (Gargari et al., 2005). In another survey in the same city, 341 male adolescents aged 14–16 years were studied. Based on NHANES-I criteria, underweight was found in 12%, overweight/obesity in 20%, and abdominal obesity in 16% of the participants. A significant difference was documented between the overweight/obese and underweight subjects regarding the energy intake: percentage of energy derived from lipid and saturated fatty acids (Shahidi et al., 2005). A total of 9312 school children aged 6–17 years were studied in Rasht, northern Iran. The overall prevalence of overweight and obesity in these school children was 14.5% and 5.6%, respectively. Overweight and obesity were more prevalent among children living in diabetic families than non-diabetic families (22.0% versus14.0%, p 〈0.0001) (Maddah, 2009a). In

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another study conducted among 1036 adolescent girls aged 14–17 years living in the rural areas of the same province, the prevalence of overweight and obesity is reported as 18.6% and 5.2%, respectively. Moreover, those girls with more educated mothers had higher prevalence of overweight than the girls with less educated mothers in rural areas (Maddah, 2009b). In a study in Lahijan, in the northern part, among 400 adolescent girls, aged 14–17 years, the prevalence of overweight and obesity were 5.3% and 14.8%, respectively. Overall, 21.5% of participants and 66.7% of obese girls had a central pattern of fat distribution (Bazhan et al., 2005). A study in Birjand, located in the north-east, determined the prevalence of weight disorders based on CDC in 2000 among 2230 students (1115 boys and 1115 girls) aged 15–18 years. The overall prevalence rates of overweight and obesity were 6.1% and 2.3%, respectively. The prevalence of overweight was 5% in high school boys and 7.1% in girls; the prevalence of obesity was 2.8% in boys and 1.8% in girls of high schools. Overweight and obesity increased with the higher educational levels of father and mother, working fathers, and private schools (Taheri et al., 2008). In a study in Neishabour, in the north- east of Iran, the prevalence of obesity was determined in 3482 (1843 boys and 1639 girls) primary school students, aged 6–12 years, by using three different sets of baseline values, namely, IOTF, CDC, and local data from Iran. Obesity was defined as having a BMI ≥ 95th percentile of each of the three sets of reference values. Prevalence rates according to Iranian reference data, CDC 2000, and IOTF 2000 were 10.9%, 5.2%, and 3.6% respectively (Baigy et al., 2008). In a study in three counties located in the central part of the country, 1000 girls and 1000 boys, aged 11–18 years, were studied. Based on CDC 2000 cut-off values, the prevalence of overweight and obesity was significantly higher in girls than in boys (10.7 ± 1.1 and 2.9 ± 0.1% versus 7.4 ± 0.9 and 1.9 ± 0.1%, respectively). Overweight was more prevalent in families with an average (p.184) income than in high-income families (9.3 ± 1.7 versus 7.2 ± 1.4%, respectively) and in those with lower-educated mothers (9.2 ± 2.1 versus11.5 ± 2.4 years of mothers’ education, respectively) (Kelishadi et al., 2003). In a study conducted in Shiraz, in the south, 803 adolescents, aged13–18 years, were studied; 11.3% were overweight and 2.9% were obese (Mostafavi et al., 2005). The differences between the age groups studied, the subjects’ living area (urban/rural), as well as the BMI cut-offs used make the comparisons difficult. In general, these studies show that the prevalence of childhood obesity in Iran is lower than Arab countries in the region and some parts of Turkey; this is suggested to be due to both genetic and lifestyle differences between Iranian and Arab nations.

Conclusions Until recent decade, childhood undernutrition had been a major nutritional problem in many Middle Eastern countries, and still is the focus of nutritional policies and related medical education curriculum; however, the higher prevalence of overweight than underweight obtained in aforementioned surveys is alarming, and confirms the importance of considering childhood

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overweight as a health priority. This should be taken into account for all Middle Eastern countries that are expected to bear one of the world's greatest increases in the burden of chronic diseases, notably diabetes and cardiovascular diseases, in the next two decades. Most countries in the Middle East have experienced a rapid epidemiologic transition with shift in the overall structure of dietary and physical activity patterns over the last few decades. Major dietary change includes a large increase in the consumption of fat and added sugar in the diet, often a marked increase in animal food products contrasted with a fall in total cereal and fibre intake. In many ways this seems to be an inexorable shift to the higher fat Western diet, reflected in a large proportion of the population consuming over 30% of energy from fat. Clearly there is the need for national strategies to integrate preventive measures including lifestyle modification, notably dietary change and encouraging physical activity, in the primary health care system and routine child health care programmes at population level. References Bibliography references: Al-Hazzaa, H.M. (2007) Rising trends in BMI of Saudi adolescents: evidence from three national cross sectional studies. Asia Pacific Journal of Clinical Nutrition 16(3), 462–466. Amin, T.T., Al-Sultan A.I., & Ali, A. (2008) Overweight and obesity and their relation to dietary habits and socio-demographic characteristics among male primary school children in Al-Hassa, Kingdom of Saudi Arabia. European Journal of Nutrition 47(6), 310–318. Baygi, F., Eshraghian, M.R., & Dorosty, A.R. (2008). Prevalence of obesity among school children in Neishabour. Journal of the Qazvin University of Medical Sciences 12(1), 73–78. de Onis, M. & Blössner, M. (2000) Prevalence and trends of overweight among preschool children in developing countries. American Journal of Clinical Nutrition 72(4), 1032–1039. Discigil, G., Tekin, N., & Soylemez, A. (2009) Obesity in Turkish children and adolescents: prevalence and non-nutritional correlates in an urban sample. Child Care Health and Development 35(2), 153–158. Dorosty, A.R., Siassi, F., & Reilly, J.J. (2002) Obesity in Iranian children. Archives of Disease in Childhood 87(5), 388–391. Galal, O. (2003) Nutrition-related health patterns in the Middle East. Asia Pacific Journal of Clinical Nutrition 12, 337–343. Gargari, B.P., Behzad, M.H., Ghassabpour, S., & Ayat, A. (2005) Prevalence of overweight and obesity among high-school girls in Tabriz, Iran, in 2001. Food and Nutrition Bulletin 26(2), 234– 237. Hamidi, A., Fakhrzadeh, H., Moayyeri, A., et al. (2006) Obesity and associated cardiovascular risk factors in Iranian children: a cross-sectional study. Pediatrics International 48(6), 566–571.

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Hossain, P., Kawar, B., & El Nahas, M. (2007) Obesity and diabetes in the developing world – a growing challenge. New England Journal of Medicine 356(3), 213–215. Jabre, P., Sikias, P., Khater-Menassa, B., Baddoura, R., & Awada, H. (2005). Overweight children in Beirut: prevalence estimates and characteristics. Child Care Health and Development 31(2), 159–165. James, P.T. (2004) Obesity: the worldwide epidemic. Clinical Dermatology 22(4), 276–280. Kelishadi, R. (2007) Childhood overweight, obesity, and the metabolic syndrome in developing countries. Epidemiology Reviews 29, 62–76. Kelishadi, R., Hashemipour, M., & Ansari, R. (2005) The impact of familial factors on obesity in Iranian children and adolescents. Pediatrics & Neonatology 2(2), 16–23. Kelishadi, R., Ardalan, G., Gheiratmand, R., et al., CASPIAN Study Group. (2007) Association of physical activity and dietary behaviours in relation to the body mass index in a national sample of Iranian children and adolescents: CASPIAN Study. Bulletin of the World Health Organization 85(1), 19–26. Kelishadi, R., Ardalan, G., Gheiratmand, R., et al., Caspian Study Group. (2008) Thinness, overweight and obesity in a national sample of Iranian children and adolescents: CASPIAN Study. Child Care Health and Development 34(1), 44–54. Kelishadi, R., Pour, M.H., Sarraf-Zadegan, N., et al. (2003) Obesity and associated modifiable environmental factors in Iranian adolescents: Isfahan Healthy Heart Program – Heart Health Promotion from Childhood. Pediatrics International 45(4), 435–442. Lafta, R.K. & Kadhim, M.J. (2006) Childhood obesity in Iraq: prevalence and possible risk factors. Annals of Saudi Medicine 26(3), 243–244. Maddah, M. (2008) Childhood obesity and early prevention of cardiovascular disease: Iranian families act too late. International Journal of Cardiology 126(2), 292–294. Maddah, M. (2009a) Association of parental diabetes with overweight in Iranian children and adolescents. International Journal of Cardiology [Epub ahead of print]. Maddah, M. (2009b) Overweight among rural girls in Iran: a terrifying prospects of cardiometabolic disorders. International Journal of Cardiology 132(3), 442–444. Malik, M. & Bakir, A. (2007) Prevalence of overweight and obesity among children in the United Arab Emirates. Obesity Reviews 8(1), 15–20. Moayeri, H., Bidad, K., Aghamohammadi, A., & Rabbani, A. (2006) Overweight and obesity and their associated factors in adolescents in Tehran, Iran, 2004–2005. European Journal of Pediatrics 165(7), 489–493.

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Childhood obesity in the Middle Eastern countries with special reference to Iran

Mohammadpour-Ahranjani, B., Rashidi, A., Karandish, M., Eshraghian, M.R., & Kalantari, N. (2004) Prevalence of overweight and obesity in adolescent Tehrani students, 2000–2001: an epidemic health problem. Public Health Nutrition 7(5), 645–648. Mostafavi, H., Dabagh Manesh, M.H., & Zare, N. (2005) Prevalence of obesity and over weight in adolescents and adult population in Shiraz. Iranian Journal of Endocrinology & Metabolism 25(7), 57–65. Musaiger, A.O., Al-Ansari, M., & Al-Mannai, M. (2000) Anthropometry of adolescent girls in Bahrain, including body fat distribution. Annals of Human Biology 27(5), 507–515. Oner, N., Vatansever, U., Sari, A., et al. (2004) Prevalence of underweight, overweight and obesity in Turkish adolescents. Swiss Medical Weekly 134(35–36), 529–533. Popkin, B.M. (2004) The nutrition transition: an overview of world patterns of change. Nutrition Reviews 62(7 Pt 2), S140–143. Popkin, B.M. & Gordon-Larsen, P. (2004).The nutrition transition: worldwide obesity dynamics and their determinants. International Journal of Obesity 28 (Suppl 3), S2–9. Shahidi, N., Mirmiran, P., & Amir Khani, F. (2005) Prevalence of obesity and abdominal obesity and their association with diet pattern of male adolescent in Tabriz. Journal of the Shaheed Beheshti University of Medical Sciences 4(28), 255–263. Tabatabaei, M., Dorosty, A.R., Siassi, F., & Rahimi Foroushani, A. (2003) Using different reference values to determine prevalence of obesity among school children in Ahwaz. Journal of School Public Health 21, 11–18. Taheri, F., Kazemi, T., Taghizadeh, B., & Najibi, G. (2008) Prevalence of overweight and obesity in Birjand adolescents. Iranian Journal of Endocrinology & Metabolism 2(10), 121–126. Wild, S., Roglic, G., Green, A., Sicree, R., & King, H. (2004) Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 27, 1047–1053. Ziaoddini, H., Kelishadi, R., Kamsari, F., Mirmoghtadaee, P., & Poursafa, P. (2010) First Nationwide Survey of Prevalence of Weight Disorders In Iranian Children at School Entry. World Journal of Pediatrics [Epub ahead of print].

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Trends in Israel

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Trends in Israel Joav Merrick Efrat Merrick-Kenig Mohammed Morad

DOI:10.1093/acprof:oso/9780199572915.003.0016

Abstract and Keywords This chapter looks at childhood overweight and obesity trends in Israel. Obesity in childhood and adolescence has increased significantly over the past 30–40 years and this increase has also been observed in Israel, where the prevalence of overweight and obesity tripled since 1967, with a steady increase since 1987 (the birth cohort born after 1970). Low SES (socioeconomic status), and low education increased the risk of obesity. Due to this increased prevalence of obesity in adolescence over the past 30–40 years there is an urgent need to focus on prevention programs, change of diet, and the promotion of a more active lifestyle with more physical activity.

Keywords: children, adolescents, epidemiology, Isreal, Israel, Middle East, social class, income, socioeconomic status, SES

Chapter summary Obesity in childhood and adolescence has increased significantly over the past 30–40 years and this increase has also been observed in Israel, where the prevalence of overweight and obesity tripled since 1967 with a steady incease since 1987 (the birth cohort born after 1970). Low SES (socioeconomic status) and low education increased the risk of obesity. Due to this increased prevalence of obesity in adolescence over the past 30–40 years, there is an urgent need to focus on prevention programmes, change of diet, and the promotion of a more active lifestyle with more physical activity.

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Introduction Obesity in childhood and adolescence presents a challenging and sometimes frustrating problem in clinical practice, but obesity is of a particular concern, because of the potential adult health risk associated with it, such as hypertension, hyperlipidemia, hypertriglyceridemia, type 2 diabetes mellitus, coronary heart disease, pulmonary and renal problems, surgical risks, and degenerative joint disease. The prevalence of overweight among children and adolescents in the United States and elsewhere has sometimes reached alarming proportions (Ogden et al., 2008). The WHO (World Health Organization) in May 1998 therefore adopted the policy of  ‘health for all in the twenty first century (HFA)’ with specific goals and targets to be reached by the different countries by 2005, 2010, 2015, and 2020 (WHO, 1999). By the year 2015, people across society should have adopted healthier patterns of living and in particular ‘healthier behaviour in such fields as nutrition, physical activity and sexuality should be substantially increased’ (WHO, 1999).

Prevalence and risk factors Israel, in spite of being in the Middle East and a multi-ethnic society, can be seen as close to eating and exercise habits of the Western world. The first Israeli National Health and Nutrition Survey (MABAT) was conducted in 1999–2001 (Keinan-Boker et al., 2005) with a sample of 2782 adults aged 25–64 years (mean 43 years), which found high obesity rates comparable to those in the United States. A prevalence of overweight was found in 39.3% and obesity in 22.9% with BMI over 30 more prevalent in women. Obesity increased with age and reached 22.4% for men and 40.4% for women aged 55–64 years (70% for Arab women in this age group). Low education was a risk factor, with the lowest obesity rate for Jewish women with an academic education (13.6%) and the highest obesity prevalence for Arab women with a basic education (57.3%). Age was a significant risk factor in males, whereas age, education, and origin (Arab and for Jews from the former Soviet Union) were for women. (p.188) The only major study conducted in childhood (Meyerovitch et al., 2007) was a computer-based study of 39 pediatric primary care centres and 21,799 medical records studied during 2001–2004 for children aged 5–7 years. In the 1556 children (10.1% of total sample) where measurements were recorded, it was found that 398 (25.6%) were overweight and 185 (11.9%) were at risk for overweight. More studies have been conducted in the adolescent age group with some as part of the HBSC (Health Behaviour in School-Aged Children) projects or cross-national surveys conducted in collaboration with the WHO Regional Office in Europe using a standard research protocol with surveys over several years. In the 1997–1998 survey of 13 European countries, Israel, and the United States (Lissau et al., 2004) data were compared with the participation of 29,242 boys and girls aged 13 and 15 years. The highest prevalences of overweight were found in the United States (12.6% in 13-year-old boys, 10.8% in girls; 13.9% in 15-year-old boys and 15.1% in 15year-old girls) with the lowest in Lithuania (1.8% in 13-year-old boys, 2.6% for girls; 0.8% in 15year-old boys and 2.1% in girls), whereas for Israel it was 3.5% for 13-year-old boys, 4.8% for girls and 6.8% for 15-year-old boys and 6.2% for girls.

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Another study from the 2001–2002 HBSC survey with 30 countries participating (Ojala et al., 2007) showed that American adolescents are still the most likely to become obese or at risk for overweight (31.7% for boys and 20.2 for girls), Lithuania still the lowest (6.4% for boys and 3.8% for girl), whereas Israel was at 15.1% for boys and 9.0% for girls at mean age of 14.5 years for the whole sample of 50,965 boys and 55,154 girls. Another source of data comes from 17-year-olds in Israel, who all have to present themselves to the Israel Defence Force (IDF) draft board for medical examination (excluded are orthodox religious Jews and Arab adolescents). One study from 2005 (Bar Dayan et al.) of 76,732 adolescents (44,330 (57.8%) males) showed obesity in 4.1% males and 3.3% in females, whereas 12.4% of males and 11.4% of females were borderline or at risk of becoming obese. Hypertension and type 2 diabetes were higher in persons with BMI over 30 and with a higher prevalence of these conditions in males than females. Obesity was also correlated to a lower level of education. A recent study (Gross et al., 2009) looked at trends in adolescent obesity for the 1967–2003 period for male Jewish conscripts (1,140,937 males born in the 1950–1987 period) and found that in the 1967–2003 period, obesity (BMI over 30) increased from 1.2% to 3.8%, whereas persons with overweight (BMI 25–30) increased from 8.5% to 12.2%. The prevalence of overweight and obesity tripled over the study period with a steady incease since 1987 (the birth cohort born after 1970) and again low SES and low education increased the risk for obesity. The trend reflects the increase in standard of living in Israel and the trend of a more sedentary life style. Besides the risk factors given earlier, low parental education and smoking have also been found as risk factors in increasing childhood obesity (Huerta et al., 2006).

Beliefs, attitudes, and adverse effects Overweight and obese children are generally aware of their problem and have to some extent an understanding of their food intake when compared to under- and normal weight children (Kaufmann et al., 1975). More interesting are the attitudes of physicians towards obesity and children (Goldman et al., 2004). One hundred and forty-four primary care physicians caring for about 100,000 children and adolescents monthly were asked questions about obesty in their clinical practice. Only 13% reported routinely weighing the children whom they examined, whereas 79% did weigh children suspected of failure to thrive or other weight disorders. The most frequent recommendation from the physicians was for referral to a dietitian (92%), physical exercise (85%), and group treatment (27%). (p.189) There have been few studies on cross-national comparisons of adolescent attempts to lose weight and weight control practices, but as part of the 2001–2002 HBSC survey of 30 countries it was found that in general, overweight and obese adolescents were more likely to be engaged in current attempts to lose weight during the past 12 months. Several studies have looked into risk factors or adverse effects associated with obesity in childhood. Pinhas-Hamiel et al. (2003) found significantly higher iron deficiency anemia in obese

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children, increased risk of B12 deficiency (Pinhas-Hamiel et al., 2006a), non-alcoholic fatty liver disease (Sagi et al., 2007), elevated triglycerides, very low density lipoprotein cholesterol, and low high density lipoprotein levels, which may place them at cardiovascular risk (Pinhas-Hamiel et al., 2007). One study (Pinhas-Hamiel et al., 2008) also found a four-fold excess risk of headaches in overweight females aged 9–17 years.

Ethnicity In a study of 512 children and adolescents in the south of Israel there was no difference between Jewish and Bedouin children (Pilpel et al., 1995), but a larger study (Kalter-Leibovici et al., 2007) with a random sample of adults showed a higher prevalence of obesity among Arab women. A multivariate analysis showed that obesity was significantly associated with BMI at age 18 years, leisure time activity, and cigarette smoking, but not ethnicity.

Quality of life In recent years quality of life (QOL) issues have become an important factor in health research. In a study of Pinhas-Hamiel et al. (2006b) among 182 children and adolescents, it was found that obese children reported a significantly lower HRQOL (health related QOL) in physical, social, and school domains than normal weight children, whereas the emotional domain scores of moderately obese children were similar, but lower for children with severe obesity. Parents of obese children perceived their child’s HRQOL lower than the children themselves.

Special populations Obesity is also a health problem in the population of persons with intellectual disability and especially in persons with Down Syndrome or Prader-Willi Syndrome. Obesity limits the capacity of the child and adolescent with Down Syndrome to participate in recreational and sports activities, and obesity also has adverse social consequences. The management of obesity in children with Down Syndrome or Prader-Willi Syndrome is complicated due to their low resting metabolic rate and low dietary intake of individual nutrients, but exercise and a vitamin-mineral supplement diet should be efforts in the right direction to minimize obesity and its adverse effects. In a study from Israel (Merrick et al., 2004) of olders persons with intellectual disability aged 40 years and older living in residential care centres (2282 persons), the mean BMI was found at 25.7, and 35% were classified as overweight. In addition, a proportion of 45.7% of those with mild intellectual disability, 45.1% with moderate, 27.1% with severe, and 15% with profound intellectual disability had a BMI over 27. So far, no major study had been conducted in Israel with children or adolescents with intellectual disability. Another special population is children and adolescents on psychotropic medicine, like medication for schizophrenia (Toren et al., 2004), who are prone to develop obesity as adverse effects of the drug treatment.

(p.190) Intervention and prevention Surgical treatment in the form of laparoscopic adjustable gastric banding (LAGB) (Abu-Abeid et al., 2003) has been used on 11 children with severe obesity (mean age 15.7 years) with nocomplications and at follow-up (mean 23 months) improvement in medical conditions and psychological well-being. Another larger surgical study of Swedish adjustable gastric band

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(SAGB) surgery (Yitzhak et al., 2006) of 60 adolescents (mean age 16 years) showed at follow-up (mean time of 39.5 months) gastric banding of very obese adolescents to be a relatively safe, satisfactory, and a reversible weight reduction procedure when properly supervised and followed up afterwards. Another approach has been to compare the conventional approach of intervention for obesity, where the child served as the agent of change, compared with a family aproach, where the parents served as the agent of change (Golan et al., 1998). This longitudinal study of 60 obese children aged 6–11 years, who were randomly assigned to these two groups, showed that the treatment with parents as the exclusive agents was superior to the conventional method during a 1-year intervention. When 50 of the original 60 children were located 7 years later, (Golan & Crow, 2004) it was shown that 7 years after termination of the intervention, the reduction in child obesity was 29% for the parent-only intervention group compared with 20.2% for the childonly group. A multidisciplinary intervention approach (dietary, behavioral, and exercise) has been employed (Eliakim et al., 2002; Nemet et al., 2005) with a 3-month intervention and long-term follow-up with signifcant effects on body weight, BMI, body fat, habitual activity, fitness, and body lipids. This programme and its principles allowed for the children to incorporate the activities in their daily life, which resulted in effect maintenance also after 1 year. Further health promotion programmes and education are needed. A study among 88 obese and 214 non-obese 12-year-old Arab children found that weight gain during the first 2 months of life and feeding patterns were independent predictors of BMI at age 12 years, and that breastfeeding seemed to have a protective effect (Shehadeh et al., 2008).

Conclusions In Israel, the prevalence of overweight and obesity tripled since 1967 with a steady incease since 1987 (the birth cohort born after 1970) and it was found that low SES and low education increased the risk for obesity. This trend reflects the increase in standard of living in Israel and the trend of a more sedentary life style. Due to this increased prevalence of obesity in adolescence over the past 30–40 years, there is an urgent need to focus on prevention programmes, change of diet, and the promotion of a more active life style with more physical activity. References Bibliography references: Abu-Abeid, S., Gavert, N., Klauser, J.M., & Szold, A. (2003) Bariatric surgery in adolescence. Journal of Pediatric Surgery 38(9), 1379–1382. Bar Dayan, Y., Elishkevits, K., Grotto, I., et al. (2005) The prevalence of obesity and associated morbidity among 17-year-old Israeli conscripts. Public Health 119(5), 385–389. Eliakim, A., Kaven, G., Berger, I., Friedland, O., Wolach, B., & Nemet, D. (2002) The effect of a combined intervention on body mass index and fitness in obese children and adolescents. A clinical experience. European Journal of Pediatrics 161, 449–454.

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Golan, M., Weizman, A., Apter, A., & Fainaru, M. (1998) Parents as the exclusive agents of change in the treatment of childhood obesity. American Journal of Clinical Nutrition 67, 1130– 1135. Golan, M. & Crow, S. (2004) Targeting parents exclusively in the treatment of childhood obesity: long-term results. Obesity Research 12(2), 357–361. Goldman, R.D., Modan-Moses, D., Bujanover, Y., Glasser, S., & Meyerovitch, J. (2004) Physicians’ attitude toward identification and management of childhood obesity in Israel. Clinical Pediatrics (Philadelphia) 43, 737–741. Gross, R., Brammli-Greenberg, S., Gordon, B., Rabinowitz, J., & Afek, A. (2009) Population-based trends in male adolescent obesity in Israel 1967–2003. Journal of Adolescent Health 44, 195– 198. Huerta, M., Bibi, H., Haviv, J., Scharf, S., & Gdalevich, M. (2006) Parental smoking and education as determinants of overweight in Israeli children. Preventing Chronic Disease 3(2), A48. Kalter-Leibovici, O., Atamna, A., Lubin, F., et al. (2007) Obesity among Arabs and Jews in Israel: a population-based study. Israel Medical Association Journal 9, 525–530. Kaufmann, N.A., Poznanski, R., & Guggenheim, K. (1975) Eating habits and opinions of teenagers on nutrition and obesity. Journal of the American Dietician Association 66(3), 264–268. Keinan-Boker, L., Noyman, N., Chinich, A., Green, M.S., & Nitzan-Kaluski, D. (2005) Overweight and obesity prevalence in Israel: finding of the first national health and nutrition survey (MABAT). Israel Medical Association Journal 7, 219–223. Lissau, I., Overpeck, M.D., Ruan, J., Due, P., Holstein, B.E., & Hediger, M.L. (2004) Body Mass Index and overweight in adolescents in 13 European countries, Israel and the United States. Archives of Pediatric and Adolescent Medicine 158, 27–33. Merrick, J., Davidson, P.W., Morad, M., Janicki, M.P., Wexler, O., & Henderson, C.M. (2004) Older adults with intellectual disability in residential care centers in Israel: health status and service utilization. American Journal on Mental Retardation 109(5), 413–420. Meyerovitch, J., Goldman, R.D., Avner-Cohen, H., Antebi, F., & Sherf, M. (2007) Primary care screening for childhood obesity: a population-based analysis. Israel Medical Association Journal 9,782–786. Nemet, D., Barkan, S., Epstein, Y., Friedland, O., Kowen, G., & Eliakim, A. (2005) Short- and long-term beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity. Pediatrics 115(4), 443–449. Ogden, C.L., Carroll, M.D., & Flegal, K.M. (2008) High body mass index for age among US children and adolescents, 2003–2006. JAMA: the Journal of the American Medical Association 299(20), 2401–2405.

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Ojala, K., Vereecken, C., Välimaa, R., et al. (2007) Attempts to lose weight among overweight and non-overweight adolescents: a cross-national survey. International Journal of Behavioral Nutrition and Physical Activity 4(paper 50). Pilpel, D., Leer, A., & Philip, M. (1995) Obesity among Jewish and Bedouin secondary school students in the Negev, Israel. Public Health Review 23(3), 253–262. Pinhas-Hamiel, O., Newfield, R.S., Koren, I., Agmon, A., Lilos, P., & Philip, M. (2003) Greater prevalence of iron deficiency in overweight and obese children and adolescents. International Journal of Obesity 2(3), 416–418. Pinhas-Hamiel, O., Doron-Panush, N., Reichman, B., Nitzan-Kaluski, D., Shalitin, S., & GevaLerner, L. (2006a) Obese children and adolescents: a risk group for low vitamin B12 concentration. Archives of Pediatric and Adolescent Medicine. 160(9), 933–936. Pinhas-Hamiel, O., Siner, S., Pilpel, N., Fradkin, A., Modan, D., & Reichman, B. (2006b) Healthrelated quality of life among children and adolescents: associations with obesity. International Journal of Obesity 30(2), 267–272. Pinhas-Hamiel, O, Lerner-Geva, L., Copperman, N.M., & Jacobsen, M.S. (2007) Lipid and insulin levels in obese children: changes with age and puberty. Obesity (Silver Spring) 15(11), 2825– 2831. Pinhas-Hamiel, O., Frumin, K., Gabis, L., et al. (2008) Headaches in overweight children and adolescents referred to a tertiary-care center in Israel. Obesity (Silver Spring) 16(3), 659–663. Sagi, R., Reif, S., Neuman, G., Webb, M., Philip, M., & Shalitin, S. (2007) Nonalcoholic fatty liver disease in overweight children and adolescents. Acta Paediatrica 96(8), 1209–1213. Shehadeh, N., Weitzer-Kish, H., Shamir, R., Shihab, S., & Weiss, R. (2008) Impact of early postnatal weight gain and feeding patterns on body mass index in adolescence. Journal of Pediatric Endocrinology and Metabolism 21(1), 9–15. Toren, P., Ratner, S., Laor, N., & Weizman, A. (2004) Benefit–risk assessment of atypical antipsychotics in the treatment of schizophrenia and comorbid disorders in children and adolescents. Drug Safety 27(14), 1135–1156. WHO (1999) Health21. The health for all policy framework for the WHO European region. World Health Organization, European health for all series 6, Copenhagen, Denmark. Yitzhak, A., Mizrahi, S., & Avinoach, E. (2006) Laparoscopic gastric banding in adolescents. Obesity Surgery 16(10), 1318–1322.

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Childhood obesity: Treatment or prevention?

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Childhood obesity: Treatment or prevention? Hammer Lawrence D.

DOI:10.1093/acprof:oso/9780199572915.003.0017

Abstract and Keywords Successful treatment of the obese child or adolescent offers one approach to preventing the long-term consequences of obesity. This chapter provides an overview of the co-morbidities of childhood obesity, the existing literature on treatment approaches, including the most recent recommendations of an Expert Panel regarding staged treatment, and the potential for reducing the prevalence and sequelae of obesity in adult life.

Keywords: weight, overweight, obesity, children, adolescents, parents, mother, clinical, treatment, prevention

Chapter summary Successful treatment of the obese child or adolescent offers one approach to preventing the long-term consequences of obesity. This chapter provides an overview of the co-morbidities of childhood obesity, the existing literature on treatment approaches, including the most recent recommendations of an Expert Panel regarding staged treatment, and the potential for reducing the prevalence and sequelae of obesity in adult life.

Persistence of obesity and key developmental periods in adipose tissue deposition A forum convened by the Robert Wood Johnson Foundation, in Princeton, USA, reaffirmed the importance of body mass index (BMI) in screening and surveillance of child obesity (Dietz et al., 2009). BMI at or above the 95th percentile for age and gender is now defined as obese, whereas BMI at or above the 85th percentile and below the 95th percentile is defined as overweight. A number of investigators have demonstrated that overweight and obesity in childhood may persist into adult life, particularly if left unidentified. Guo et al. (2002) found that among obese boys (BMI 〉 95 percentile), those 8 years of age and younger had only a 20% likelihood of adult

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obesity (age 35 years), whereas the likelihood increased to over 30% for obese boys 9 to 12 years of age, and to more than 50% for obese boys 13 years of age and older. Similarly, among obese girls 8 years and younger, the likelihood of obesity at 35 years of age increased from greater than 30% to greater than 50% for obese girls 9 to 12 years of age and to greater than 66% for obese girls 13 years of age and older. In a large cohort of infants followed into adult life, obese children, less than 3 years of age, with two non-obese parents, were at very low risk of remaining obese into adult life, whereas obese children older than 3 years of age were found to have an increasing risk of adult obesity that was correlated with their own BMI. The presence of parental obesity more than doubled the risk of later adult obesity among those children less than 10 years of age without obese parents (Whitaker et al., 1997). The genetic contribution to obesity has been estimated to be as high as 70% (Maes et al., 1997), with known genetic effects on adipose tissue distribution, energy expenditure, lipoprotein lipase activity, lipolysis, and variation in the regulation of food intake (Hebebrand et al., 2001; Ravussin & Bogardus, 2000). Treatment approaches using gene therapy may some day inhibit these genetic contributions and their associated obesity syndromes. Until then, treatment of obesity in childhood and adolescence depends on effective behaviour change, with limited use of pharmacotherapy or weight loss surgery in a selected subgroup of patients.

(p.196) Sequelae of obesity in childhood and in adult life The medical risks that may be associated with obesity in adult life include potential impacts of excessive body fatness on organ systems, from the musculoskeletal to the integumentary, including potentially adverse effects on the brain, liver, kidneys, heart, lungs, and endocrine systems (Must & Strauss, 1999). Some of these same disorders are now seen with greater frequency in younger populations. Well-known consequences of severe obesity, such as hypertension, hyperlipidemia, slipped capital femoral epiphyses, and Blount’s Disease have now been joined by fatty liver disease, obstructive sleep apnea, renal tubular disease, pseudotumor cerebri, and Type II diabetes mellitus, as diseases that may be encountered in obese children and adolescents (Dietz, 1998; Must & Strauss, 1999). The consequences of these comorbidities, whether they develop during childhood or later in life, are significant. For example, diabetes can lead to renal failure, vision loss, cerebrovascular disease, heart disease, and long-term risks of deep tissue infection requiring amputation of the lower extremities. Reversal of obesity can lead to reduction in the risk of Type II diabetes (Reinehr et al., 2004) and reduction in its associated comorbidities related to peripheral vascular disease (Reinehr et al., 2006; Wunsch et al. 2006). The social and psychological consequences of obesity may begin during childhood, with stigmatization and social isolation (Dietz, 1998) and extend into adult life, including lower household income, fewer years of education, higher rates of poverty, and lower marriage rates (Gortmaker et al., 1993). Thirty percent of adolescents undergoing evaluation for weight loss surgery met criteria for clinically significant depression using a self-report measure and 45% met criteria based on parent report (Zeller et al., 2006). Quality of life may be compromised for obese children and adolescents (Schwimmer et al., 2003).

Approaches to obesity treatment Recommendations that are now routinely offered to prevent obesity in childhood are nearly identical to strategies used when treating children who have already developed obesity.

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Whitaker has identified four specific behaviours that can affect energy balance and that can be addressed during routine well-child care (Whitaker, 2003). These behaviours are felt to be risk factors that are modifiable through parent intervention and control over the child’s environment, such as amount of screen time (video, computer and television use), outdoor play, breastfeeding, and reduction in the consumption of sugar sweetened drinks (Whitaker, 2003). In 2005, the Institute of Medicine (IOM) issued a report that included several recommendations for physicians in their efforts to counter the increasing prevalence of child obesity (IOM, 2005), beginning with the routine measurement of height and weight, longitudinal tracking of BMI, and the use of evidence-based counseling. The IOM further recommended that medical professional organizations disseminate evidence-based clinical guidance, establish programmes on obesity prevention, coordinate with each other to present a consistent message, and include obesity prevention knowledge and skills across the spectrum of professional education and in their certification examinations. Behavioural treatment A risk-factor based approach to prevention would target modifiable factors that are identified as contributing to an increased risk of child obesity. Factors, such as the child’s early feeding experience and parenting style, offer opportunities for targeted intervention. Agras et al. (2004) demonstrated that parenting style, when coupled with a child temperament that was ‘difficult’ and ‘hard to soothe’ led to an increase in risk of child obesity. Children whose temperament is ‘difficult’ (those with higher negativity and intensity, and lower rhythmicity, approachability, and adaptability) are (p.197) more frequently irritable, which then may encourage parents to overfeed as a soothing technique (Carey, 1985). Agras et al. (2004) found that children whose parents reported tantrums over food and whose temperament scores were higher on anger and frustration and lower on soothability had an increased risk of later overweight. A pilot intervention study targeting such at-risk toddlers is currently underway (Agras, personal communication). Parenting style can influence child eating behaviour and food intake (Drucker et al., 1999). Excessive parental control of dietary intake, rather than self-regulation by the child, may also increase the child’s risk of obesity, suggesting another potential target for intervention (Johnson & Birch, 1994). Inactivity also contributes to weight gain. Interventions to decrease sedentary behaviours, including television viewing, or to increase physical activity, are associated with changes in percentage overweight and aerobic fitness (Epstein et al., 2000). Likewise, efforts to reduce television viewing can indirectly influence change in BMI and prevalence of obesity over time in nonclinical populations (Robinson, 1999). The best examples of treatment studies of children with their parents are those of Epstein et al. (1994). Their treatment programmes incorporated behavioural strategies, such as goal setting, self-monitoring, record review, contracting, praise, environmental control, cognitive restructuring, along with an emphasis on anticipation, periodic reassessment, and maintenance. Epstein’s ‘Traffic Light Diet’ categorized foods as more or less desirable and then used behavioural techniques to encourage a reduction of less desirable foods and encouragement of more desirable foods.

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Childhood obesity: Treatment or prevention?

Early treatment must have a sustained impact if it is to reduce the long-term consequences of obesity. Epstein et al. (1994) reported follow-up results of their family-based group treatment programmes at 5 and 10 years. At the 10-year follow-up, only about one-third of the participants had maintained at least a 20% decrease in percentage overweight and only 30% of the participants were no longer overweight (Epstein et al.,1994). Very few controlled studies of behavioural treatment for child and adolescent obesity have been published, with varying duration of follow-up. After systematically reviewing nine treatment studies, with follow-up as long as two years, Gibson et al. (2006) concluded that there was insufficient evidence to support the use of behavioral treatment for long-term management of child obesity. Medications At the present time, there are only two drugs that are approved for use in the USA by the Food and Drug Administration (FDA) in the treatment of obese adolescents. Sibutramine, (Meridia ®), a norepinephrine/serotonin reuptake inhibitor, is approved for adolescents at least 16 years of age. In comparison to a placebo control group, adolescents who were enrolled in a behavioural treatment programme, and received sibutramine, experienced greater weight loss during their initial 6 months of treatment, but this difference disappeared after a 6-month open label treatment period (Berkowitz et al., 2003) and side effects led to discontinuation of the drug or reduction in dosage in 40% of participants. Likewise, Orlistat (Xenical ®), a gastrointestinal lipase inhibitor, approved for use in patients at least 12 years of age and now available in the USA without a prescription, also has an undesirable side-effect profile, including fatty/oily stools and faecal incontinence (Chanoine et al., 2005). Neither of these medications has been shown to have efficacy for long-term weight management in the pediatric population. Weight loss surgery Surgical treatment for obesity takes advantage of either a reduction in the size of the stomach (restrictive) or the removal of a portion of the small bowel (malabsorptive). The most commonly (p.198) performed bariatric procedure performed today is the Roux-en-Y gastric bypass, which is both restrictive and malabsorptive, as it combines elements of both gastroplasty (reduction in the size of the stomach to a 15–30 ml pouch) and intestinal bypass (resection of 75–150 cm of the small bowel). An alternative approach involves placement of a band around the upper stomach, usually laporascopically, with a subcutaneous reservoir that is used to adjust the tightness of the band. Although adjustable gastric banding can be reversed by removal of the band, the band has not been approved by the U. S. Food and Drug Administration for patients under 18 years of age. Data concerning long-term outcomes of bariatric surgery for adolescents are beginning to emerge. Early reports of successful adolescent bariatric surgery included a group of 10 patients, 15 to 17 years of age, all of whom had a Roux-en-Y gastric bypass at one centre and had a mean weight loss of 54 kg (Strauss et al., 2001). Seven studies of adolescent bariatric surgery were reviewed by Pratt et al. (2009). One-year outcomes for 30 adolescents following Roux-en-Y procedures at three centres showed a significant change in mean BMI, from 56.5 kg/m2 to 35.8 kg/m2, accompanied by significant improvements in insulin sensitivity and lipid profiles. Postoperative complications were found in nearly half of all participants, including one death due to

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colitis secondary to Clostridium difficile, as well as serious complications in four patients and minor complications in nine patients. Complications included persistent iron deficiency anemia, peripheral neuropathy secondary to vitamin deficiency, shock, beriberi, as well as staple line leak and intestinal obstruction. Favourable outcomes following weight loss surgery in adolescents provide some degree of assurance that weight loss is accompanied by resolution of major comorbidities like Type II diabetes mellitus (Lawson et al., 2006), however long-term outcome studies following weight loss surgery have not yet been reported. Although the goals of weight loss surgery are often tied to the comorbidities of severe obesity, these immediate improvements must be accompanied by life-long change in diet, exercise, and lifestyle in order to expect maintenance of weight loss.

What are the risks of treatment? In their 10-year follow-up paper, Epstein et al. (1994) reported increased rates of psychiatric disorders, including depression, substance abuse, and eating disorders, among patients who had participated in the ‘Traffic Light Diet’. Whether these conditions could be classified as ‘complications’ of treatment or the expression of pre-existing conditions, could not be determined from their analyses. Studies of adult patients with Anorexia Nervosa and Bulimia frequently report past histories of obesity (Jacobi et al., 2004). More data are also needed on the psychological outcomes of surgical weight loss. Although Herpertz et al. (2004) found no significant relationship between pre-operative mental health status in adults undergoing weight loss surgery and their post-operative psychological outcomes, concern remains that adolescents undergoing weight loss surgery must have consistent ongoing mental health follow-ups (Pratt et al., 2009).

Staged treatment: recommendations of the expert committee In February 2004, the American Medical Association convened an expert committee, representing 15 professional organizations, to formulate a series of recommendations concerning the assessment, prevention, and treatment of child and adolescent obesity. The expert committee used a conceptual framework of chronic care, with an emphasis on selfmanagement and family involvement, in all aspects of assessment, prevention, and treatment (Barlow et al., 2007). (p.199) The expert committee recognized a continuum from prevention to treatment, with a good deal of overlap between recommendations for prevention (Davis et al., 2007) and for treatment (Spear et al., 2007). Many behaviours that are considered potential targets for obesity prevention are also included as components of obesity treatment. The expert committee endorsed a sequenced approach to treatment, labelled as Stages 1 through 4, increasing in intensity with the child or adolescent’s severity of obesity and their experience with previous stages of treatment (Spear et al., 2007). During Stage 1, also called Prevention Plus (PP), the guideline endorses a variety of change targets, such as reducing sweetened beverages, increasing dairy products and fiber, increasing fruits and vegetables, reduction in breakfast skipping and patronage of fast food restaurants, modest energy restriction, increasing physical activity, and reducing sedentary time. The committee

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Childhood obesity: Treatment or prevention?

recommended that the PP protocol be used in counseling any child or adolescent, 2 through 18 years of age, whose BMI exceeds the 85th percentile, with a goal of weight maintenance, leading to a slow reduction in BMI percentile over time. For those children and adolescents unable to reduce their BMI percentile in PP, treatment Stage 2, also called Structured Weight Management (SWM), can be offered in the setting of the medical home or primary care setting. SWM includes a more structured dietary plan that emphasizes balanced-macronutrient caloric reduction and reduction in energy-dense foods, while insuring adequate energy and protein intake. SWM also includes more effective behavioural strategies to reinforce reduction in screen time to less than 1 hour daily and increase supervised physical activity to at least 1 hour daily. Effective use of SWM should result in weight loss, generally less than 1 lb per week for those up to 11 years of age and less than 2 lb per week for those 12 to 18 years of age, with follow-up on a monthly basis. After 3 to 6 months in SWM, insufficient progress would lead to more intensive management in Stage 3, also called Comprehensive Multidisciplinary Intervention (CMI). CMI incorporates all of the components of SWM, but at a higher intensity, generally outside the primary care setting. In a Stage 3 pediatric weight management programme, more frequent professional contact is maintained, at least weekly, for a minimum of 8–12 weeks, with ongoing monthly follow-up, either face-to-face, by telephone, or using other electronic modalities. CMI incorporates more formal parental involvement, at least until 12 years of age, with gradual reduction in parent involvement during the teen years, in the behavioural components of the programme to reinforce more change in diet and physical activity. The more intensive, structured, approach of CMI should result in weight loss up to 2 lbs per week for children 6–18 years of age, or up to 1 lb per week for those 2 to 5 years of age. For severely obese patients who are unable to achieve success after 3 to 6 months with CMI, Stage 4, or Tertiary Care Intervention (TCI), incorporates the elements of CMI through a multidisciplinary team of professionals with expertise in child obesity, behavioural counseling, nutrition, and exercise. TCI may be offered in a tertiary care centre or in the context of a residential setting (e.g. camp, boarding school), or in the home setting, and may include meal replacement, very low calorie diets, pharmaceutical treatment, and bariatric surgery. TCI would generally only be recommended for adolescents older than 11 years of age with BMI ≥ 95th percentile and significant comorbidities of obesity, or with BMI ≥ 99th percentile who have not already shown improvement during stages 1 to 3. These four stages of treatment, ranging from PP to TCI, may all be considered on a continuum that is based on the importance of achieving a healthy weight, with BMI under the 85th percentile. With the goal of achieving a healthy weight comes the long-term goal of reducing the comorbidities associated with obesity. Whether primary prevention is ultimately necessary to prevent (p.200) these complications of obesity or whether these can be avoided through effective interventions that reduce BMI percentile after the child has already exceeded the 85th or 95th percentile will only be known after an adequate evidence base has been analyzed. More data are needed on the long-term risks associated with obesity treatment and the potential benefit of long-term weight management and sustained reduction in BMI percentile beginning during childhood or adolescence.

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Conclusions In 2005, the American Heart Association published a scientific statement (Daniels et al., 2005) emphasizing the importance of managing overweight in childhood in order to reduce later adverse outcomes related to Type II diabetes mellitus, obstructive sleep apnea, hypertension, dyslipidemia, and the metabolic syndrome. At this time, a few studies support this concept, including studies by Reinehr et al. (2006) and Wunsch et al. (2006), which demonstrated improvements in cardiovascular and metabolic risk factors, and intima-media thickness in children who reduced their BMI z-score by at least 0.5 while participating in a behavioural weight loss programme. In summary, a great deal more research is needed to support the efficacy of treatment of obesity during childhood or adolescence to reduce the likelihood of adult obesity. Although successful treatment of children has a beneficial impact on cardiovascular and metabolic risk, more longterm follow-up data are needed to support any recommendations for widespread treatment of obese children and adolescents in order to prevent the comorbidities of adult obesity. The new Expert Committee’s Staged Treatment approach will also have to be tested in long-term followup studies in order to balance its potential efficacy against any risks that accompany the behavioural, pharmacological, and surgical components along the continuum from Prevention Plus to Tertiary Care Intervention. References Bibliography references: Agras, W.S., Hammer, L.D., McNicholas, F., & Kraemer, H.C. (2004) Risk factors for childhood overweight: a prospective study from birth to 9.5 years. Journal of Pediatrics 145, 20–25. Barlow, S.E. and the Expert Committee (2007) Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 120, S164–S192. Berkowitz, R.I., Wadden, T.A., Tershokovec, A.M., & Cronquist, J.L. (2003) Behavior therapy and sibutramine for the treatment of adolescent obesity: A randomized clinical trial. JAMA: the Journal of the American Medical Association 289, 1805–1812. Carey, W.B. (1985) Temperament and increased weight gain in infants. Journal of Developmental and Behavioural Pediatrics 6, 128–131. Chanoine, J-P., Hampl, S., Jensen, C., Boldrin, M., & Hauptman, J. (2005) Effect of orlistat on weight and body composition in obese adolescents. JAMA: the Journal of the American Medical Association 293, 2873–2883. Daniels, S.R., Arnett, D.K., Eckel, R.H., Gidding, S.S., Hayman, L.L., & Kumanyika, S. (2005) Overweight in children and adolescents: pathophysiology, consequences, prevention and treatment. Circulation 111, 1999–2012. Davis, M.M., Gance-Cleveland, B., Hassink, S., Johnson, R., Paradis, G., & Resnicow, K. (2007) Recommendations for prevention of childhood obesity. Pediatrics 120, S229–S253.

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Dietz, W.H. (1998) Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics 101, 518–525. Dietz, W.H., Story, M.T., & Leviton, L.C. (2009) Introduction to issues and implications of screening, surveillance, and reporting children’s BMI. Pediatrics 124, (Suppl1) s1–s2. Drucker R.R., Hammer, L.D., Agras, W.S., & Bryson, S. (1999) Can mothers influence their child’s eating behavior? Journal of Developmental and Behavioural Pediatrics 20, 88–92. Epstein, L.H., Paluch, R.A., Gordy, C.C., & Dorn, J. (2000) Decreasing sedentary behaviors in treating pediatric obesity. Archives of Pediatric and Adolescent Medicine 154, 220–226. Epstein, L.H., Valoski, A., Wing, R.R., & McCurley, J. (1994) Ten-year outcomes of behavioral family-based treatment for childhood obesity. Health Psychology 13, 373–383. Gibson L.J., Peto, J., Warren, J.M., & dos Santos Silva, I. (2006) Lack of evidence on diets for obesity for children: a systematic review. International Journal of Epidemiology 35, 1544–1552. Gortmaker, S.L., Must, A., Perrin, J.M., Sobol, A.M., & Dietz, W.H. (1993) Social and economic consequences of overweight in adolescence and young adulthood. New England Journal of Medicine 329, 1008–1012. Guo, S.S., Wu, W., Chumlea, W.C., & Roche, A.F. (2002) Predicting overweight and obesity in adulthood from body mass index values in childhood and adolescence. American Journal of Clinical Nutrition 76, 653–658. Hebebrand, J., Sommerlad, C., Geller, F., Gorg, T., & Hinney, A. (2001) The genetics of obesity: practical implications. International Journal of Obesity 25 (suppl.) S10–S18. Herpertz, S., Kielmann, R., Wolf, A.M., Hebebrand, J., & Senf, W. (2004) Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review. Obesity Research 12, 1554–1569. Institute of Medicine Committee on Prevention of Obesity in Children and Youth. (2005) Preventing Childhood Obesity: Health in the Balance. Washington, DC: The National Academies Press. Jacobi, C., Hayward, C., de Zwaan, M., Kraemer, H.C., & Agras, W.S. (2004) Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for general taxonomy. Psychology Bulletin 130, 19–65. Johnson, S.L. & Birch, L.L. (1994) Parents’ and children’s adiposity and eating style. Pediatrics 1994, 654–661. Lawson, M.L., Kirk, S., Mitchell, T., Chen, M.K., Loux, T.J., & Daniels, S.R. (2006) One-year outcomes of Roux-en-Y gastric bypass for morbidly obese adolescents: a multicenter study from the Pediatric Bariatric Surgery Study Group. Journal of Pediatric Surgery 41, 137–143.

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Maes, H.H.M., Neale, M.C., Eaves, L.J. (1997) Genetic and environmental factors in relative body weight and human adiposity. Behavioural Genetics 27, 325–351. Must, A. & Strauss, R.S. (1999) Risks and consequences of childhood and adolescent obesity. International Journal of Obesity 23 (suppl 2) S2–S11. Pratt, J.S.A., Lenders, C.M., Dionne, E.A., Hoppin, A.G., Hsu, G.L.K., & Inge, T.H. (2009) Best practice updates for pediatric/adolescent weight loss surgery. Obesity 17, 901–910. Ravussin, E. & Bogardus, C. (2000) Energy balance and weight regulation: genetics versus environment. British Journal of Nutrition 83 (suppl.), S17–S20. Reinehr, T., de Sousa, G., Toschke, A.M., & Andler, W. (2006) Long-term follow-up of cardiovascular disease risk factors in children after an obesity intervention. American Journal of Clinical Nutrition 84, 490–496. Reinehr, T., Kiess, W., Kapellen, T., & Andler, W. (2004) Insulin sensitivity among obese children and adolescents, according to degree of weight loss. Pediatrics 114, 1569–1573. Robinson, T.N. (1999) Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA: the Journal of the American Medical Association 282, 1561–1567. Schwimmer, J.B., Burwinkle, T.M., & Varni, J.W. (2003) Health-related quality of life and severely obese children and adolescents. JAMA: the Journal of the American Medical Association 289, 1813–1819. Spear, B.A., Barlow, S.E., Ervin, C., Ludwig, D.S., Saelens, B.E., & Schetzina, K.E. (2007) Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics 120, S254–S288. Strauss, R.S., Bradley, L.J., & Brolin, R.E. (2001) Gastric bypass surgery in adolescents with morbid obesity. Journal of Pediatrics 138, 499–504. Whitaker, R.C. (2003) Obesity prevention in pediatric primary care. Four behaviors to target. Archives of Pediatrics and Adolescent Medicine 157, 725–727. Whitaker, R.C., Wright, J.A., Pepe, M.S., Seidel, K.D., & Dietz, W.H. (1997) Predicting obesity in young adulthood from childhood and parental obesity. New England Journal of Medicine 337, 869–873. Wunsch, R., de Sousa, G., Toschke, A.M., & Reinehr, T. (2006) Intima-media thickness in obese children before and after weight loss. Pediatrics 118, 2334–2340. Zeller, M.H., Roehrig, H.R., Modi, A.V., Daniels, S.R., & Inge, T.H. (2006) Health-related quality of life and depressive symptoms in adolescents with extreme obesity presenting for bariatric surgery. Pediatrics 117, 1155–1161.

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Relevant health education and health promotion theory for childhood obesity prevention

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Relevant health education and health promotion theory for childhood obesity prevention Karen Glanz Brian E. Saelens

DOI:10.1093/acprof:oso/9780199572915.003.0018

Abstract and Keywords Understanding and influencing obesity is central to population-health strategies for disease prevention and health promotion. The health education that are most fundamental to preventing childhood obesity involve moderating food consumption and ensuring adequate physical activity. While the task may appear to be simple, in fact it is very complex because the determinants and contexts of the health promotion, and the disease prevention themselves, are multidimensional and occur at multiple levels.This chapter proposes that the most important contribution of health education and health promotion theory to solving widespread health problems is in providing ways of thinking that help to understand the factors contributing to health-related behaviours, and to develop and evaluate broad-based public health and policies based on this understanding. It provides a broad perspective and examples of how health education and promotion theories and corresponding research can assist in developing more effective public health approaches to the prevention of childhood obesity around the world.

Keywords: obesity, school, health education, health promotion, theory, prevention, eating disorders

Chapter summary Understanding and influencing behaviour is central to population-health strategies for disease prevention and health promotion. The behaviours that are most fundamental to preventing childhood obesity involve moderating food consumption and ensuring adequate physical activity. While the task may appear to be simple, in fact it is very complex because the determinants and contexts of the behaviours, and the behaviours themselves, are multidimensional and occur at multiple levels. In this chapter, we propose that the most important contribution of health

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Relevant health education and health promotion theory for childhood obesity prevention

education and health promotion theory to solving widespread health problems is in providing ways of thinking that help to understand the factors contributing to health-related behaviours, and to develop and evaluate broad-based programmes and policies based on this understanding. In this chapter, we provide a broad perspective and examples of how health education and promotion theories and corresponding research can assist in developing more effective public health approaches to the prevention of childhood obesity around the world.

Importance of understanding influences on health behaviour The most successful public health programmes and initiatives are based on an understanding of health behaviours and the context in which they occur (Glanz et al., 2008). Strategic planning models such as the PRECEDE/PROCEED model and Intervention Mapping provide structured frameworks for developing and managing public health interventions and improving them through evaluation (Bartholomew et al., 2006; Green & Kreuter, 2005). Health education and promotion theories, often referred to as ‘health behavior theory’, can contribute to programme planning and evaluation, and advance research to test innovative intervention strategies (Glanz et al., 2008). Interventions, broadly defined herein to include environment and policy changes as well as more traditional programmes to improve health behaviour, can be best designed with an understanding of relevant theories of behaviour change and the ability to use them skilfully. A growing body of evidence suggests that interventions developed with an explicit theoretical foundation or foundations are more effective than those lacking a theoretical base and that some strategies that combine multiple theories and concepts have larger effects (Ammerman et al., 2002; Legler et al., 2002; Noar et al., 2007). The science and art of using these theories reflect an amalgamation of approaches, methods, and strategies from social and health sciences. Influential work draws on the theoretical perspectives, research, and practice tools of such several disciplines including (p.204) psychology, sociology, social psychology, anthropology, communications, nursing, economics, and marketing (Glanz & Bishop, 2010). The need for multidisciplinary perspectives and inputs is particularly relevant to eating and activity behaviours, which are ubiquitous, occur daily, and are influenced by multiple factors.

What is theory? A theory presents a systematic way of understanding events, behaviours, and/or situations (Glanz & Rimer, 1995). A theory is a set of interrelated concepts, definitions, and propositions that explain or predict events or situations by specifying relations among variables. Theories can guide the search to understand why people do or do not practise health promoting behaviours; help identify what information is needed to design an effective intervention strategy, and provide insight into how to design a programme or policy so it has the desired outcome (Glanz et al., 2008). Theories and models help explain behaviour, as well as suggest how to develop more effective ways to influence and change behaviour. Within health behaviour and promotion theories, the notion of generality, or broad application, is important (Glanz et al., 2008). These theories are by their nature applicable across various health behaviours and therefore not content/topic-specific. Therefore, experts working on a specific health problem, such as childhood obesity prevention, should be familiar with a variety of theories and be prepared to consider their applicability in a particular geographical and sociocultural environment.

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Relevant health education and health promotion theory for childhood obesity prevention

Multiple determinants and multiple levels of health behaviour Many social, cultural, and economic factors contribute to the development, maintenance, and change of health behaviour patterns (Smedley & Syme, 2000). No single factor or set of factors adequately accounts for why people eat as they do, smoke or do not smoke, and are active or sedentary. Contributory factors also exist at multiple levels. For example, knowledge, attitudes, reactions to stress, and motivation are important individual determinants of health behaviour. Families, social relationships, socioeconomic status, culture, and geography are other important influences beyond individual determinants. A broad understanding of some of the key factors and models for understanding behaviours and behaviour change can provide a foundation for well-informed public health programmes, help identify the most influential factors for a particular person or population, and enable programme developers and policy and other decision makers to focus on the most salient issues. Traditionally, health educators and promoters focused on intra-individual factors such as a person’s beliefs, knowledge, and skills. In fact, many behaviour change programmes for reducing risk factors continue to have these emphases (Kok et al., 2008). However, the rapid rise of the obesity epidemic and findings that most interventions to help individuals change their eating and physical activity behaviours had weak and/or short-lived effects (Kumanyika et al., 2000; Marcus et al., 2000) have revealed the limitations of the dominant individually focused models of behaviour. It is now generally recognized that public health and health promotion interventions are most likely to be effective if they embrace a broader ecological perspective (McLeroy et al., 1988; Sallis et al., 2008). That is, they should not only be targeted directly at individuals but should also affect interpersonal, organizational, and environmental factors influencing an individual’s health behaviour. This is clearly illustrated when one thinks of the students eating lunch at school. The students may bring their food with them from home or buy food (or receive free lunch) from school cafeterias, vending machines, and nearby stores. The decision to bring or buy lunch is likely influenced by various factors, including personal and family preferences, habits, family (p.205) economic factors, and peer influences, among others. If purchasing food or drinks, nutrition information, availability, cost, and placement, among other things is likely influential. The process is complex and determined not only by multiple factors but by factors at multiple levels. A central lesson of ecological models is that, because behaviour is influenced at multiple levels, the most effective interventions should operate at multiple levels. However, most diet and physical activity interventions have attempted to build knowledge, motivation, and behavior change skills in individuals, without changing the environments that individuals live in. Such interventions are based on individual-level theories of health promotion that emphasize the importance of individual-level factors (e.g., knowledge) on health behaviours and health behaviour change. For example, after a nutrition education lesson in class that encouraged students to choose fruits and vegetables, they could go to the lunchroom where the only choice was between hamburgers and pizza. Community and school leaders could encourage children to walk to school as a way of being more active, but those admonishments would be ineffective if they do not also address the lack of sidewalks or speed of cars in the neighbourhood where the children would walk. Thus, environments and policies that do not support healthful behaviours

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Relevant health education and health promotion theory for childhood obesity prevention

or make unhealthful behaviours less likely can make it difficult, dangerous, or impossible to use knowledge, motivation, and skills. Similarly, just changing physical activity or food environments may not be sufficient to lead to substantial behaviour change. Building a sidewalk or stocking fresh fruits and vegetables in convenience stores, by themselves, may change behaviour very little. Based on ecological models we expect the most effective obesity prevention strategies to create environments that make it easy to make the healthy choice (e.g., renovate the park, stock skim milk in stores) and harder to make the unhealthy choice (e.g., slower elevators, fewer unhealthy food options), enhance social norms and social support for healthier options (e.g., with a media campaign), educate and motivate individuals to take advantage of the opportunities for healthy behaviours, and use policy (e.g., reduce prices for healthy foods, zone for more mixed land use) to also enhance healthfulness.

Important theories and their key constructs There are several available and widely used models and theories of behaviour change that are applicable to childhood obesity prevention. This section describes five theoretical models that are in current use and make unique contributions to the interventionist’s tool kit. They are: consumer information processing, social cognitive theory, the stages of change construct from the transtheoretical model, the theory of planned behaviour, and social ecological models (Glanz & Rudd, 1993; Glanz et al., 2008). Three theories are considered to be targeted primarily at the individual level or are ‘intraindividual’ theories (Glanz et al., 1990; Glanz et al., 2008). Although the most broad obesity prevention programmes must address multiple levels of influence on behaviour, it is also important not to lose sight of the building blocks of multicomponent programmes and strategies. We highlight consumer information processing, the theory of planned behaviour, and the stages of change construct from the transtheoretical model here because they each contribute to how experts from many countries can think about obesity prevention. At the ‘interpersonal’ level, social cognitive theory (SCT) is particularly relevant, and finally we briefly recap the social ecological model and its relevance. Consumer information processing People require information about how to choose nutritious foods in order to follow guidelines for healthy eating. A central premise of consumer information processing theory is that individuals (p.206) can process only a limited amount of information at one time. People tend to seek only enough information to make a satisfactory choice. They develop heuristics, or rules of thumb, to help them make choices quickly within their limited information-processing capacity (Rudd & Glanz, 1990). The nutrition information environment, in particular, is often complex and confusing, especially when programmes rely heavily on print nutrition-education materials that may be written at a sophisticated level in terms of wording and concepts. There are several implications of consumer information processing theory for nutrition intervention. Information that is provided should be made easily accessible, not confusing, and processable with limited effort. Messages that are food-focused rather than nutrient-focused may be particularly helpful (Gehling et al., 2004). Nutrition information and guidelines for

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Relevant health education and health promotion theory for childhood obesity prevention

health-enhancing physical activity should be suited to the comprehension level of the audience, and be either portable or available at or near the point of food selection. The current interest in and application of menu labelling, the provision of nutrition information on menus and menu boards at restaurants, is an example of the application of the consumer information processing model. Front-of-pack or shelf labels for packaged foods are another example of applying consumer information processing for healthier eating. Theory of planned behaviour Often people’s food choices are influenced by how they view the actions they are considering (e.g., are these French fries healthy?), and whether they believe important others such as family members or peers would approve or disapprove of their behaviour (e.g., does anyone I know care whether I eat unhealthful foods or not?). The theory of planned behaviour (TPB), which evolved from its predecessor, the theory of reasoned action (TRA), focuses on the relationships between behaviour and beliefs, attitudes, subjective norms, and intentions (Montaño & Kasprzyk, 2008). The concept of perceived behavioural control – which involves the belief about whether one can control his or her performance of a behaviour – that is, they may feel motivated if they feel they ‘can do it’. A central assumption of TPB is that ‘behavioral intentions’, a cognitive appraisal of the likelihood that one will engage in a future behaviour, are the most important determinants of behaviour (Ajzen, 1991). TPB has been applied widely to help understand and explain many types of behaviour, including eating behaviour and physical activity. The theoretical constructs from TPB may be used to help design an intervention, and also can help explain why some people changed and others did not after an intervention, like a nutrition education programme or communication campaign. These latter interventions implicitly rely on changing an individual’s perceived behavioural control, postulating that once an individual learns that healthy eating is related to better health and has the knowledge to distinguish between unhealthful and healthful foods, that behavioural intentions to eat more healthfully will occur and lead to behaviour change. Stages of change Long-term behaviour change for obesity prevention involves multiple actions and adaptations over time. Some people may not be ready to attempt some or most changes, whereas others may have already begun implementing diet modifications. The construct of ‘stage of change’ is a key element of the transtheoretical model of behavior change, and proposes that people are at different stages of readiness to adopt healthful behaviours (Prochaska et al., 2008). The notion of readiness to change, or stage of change, has been examined in dietary behaviour research and in physical activity research, and has been found useful in explaining and predicting eating habits and exercise. Stages of change is a heuristic model that describes a sequence of steps in successful behaviour (p.207) change: precontemplation (no recognition of need for or interest in change); contemplation (thinking about changing); preparation (planning for change); action (adopting new habits); and maintenance (ongoing practice of new, healthier behaviour) (Prochaska et al., 1992). People do not always move through the stages of change in a linear manner – they often recycle and repeat certain stages; for example, individuals may relapse and go back to an earlier stage depending on their level of motivation and self-efficacy.

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The stages of change model can be used both to help understand why children and adolescents might not be ready to undertake dietary change or increases in physical activity, and to improve the success of obesity prevention interventions. Youth can be classified according to their stage of change by asking a few simple questions – are they interested in trying to change their eating and/or activity patterns, thinking about changing, ready to begin a new behaviour, already making changes, or trying to sustain changes they have been following for some time? By knowing the current stage, interventions could be matched to stage in order to maximize behaviour change for individuals at different stages and to move individuals to higher stages. Social cognitive theory Social cognitive theory (SCT), the cognitive formulation of social learning theory that has been best articulated by Bandura (Bandura, 1986; 1997), explains human behaviour in terms of a three-way, dynamic, reciprocal model in which personal factors, environmental influences, and behaviour continually interact. SCT synthesizes concepts and processes from cognitive, behaviouristic, and emotional models of behaviour change, so it can be readily applied to interventions for disease prevention and management. A basic premise of SCT is that people learn not only through their own experiences, but also by observing the actions of others and the results of those actions. Key constructs of social cognitive theory that are relevant to obesity prevention include observational learning, reinforcement, self-control, and self-efficacy (Glanz, 1997). Self-efficacy, or a person’s confidence in his or her ability to take action and to persist in that action despite obstacles or challenges, seems to be especially important for influencing dietary and physical activity change efforts (Bandura, 1997). There are many interventions based on SCT that employ strategies that attempt to enhance self-efficacy. For instance, goalsetting and self-monitoring are thought to increase feelings of self-efficacy and seem to be particularly useful components of effective obesity interventions. In obesity prevention programmes in school or community settings, it is possible to easily incorporate activities such as cooking demonstrations, problem-solving discussions, and selfmonitoring that are rooted in SCT. Also, the key SCT construct of reciprocal determinism means that a person can be both an agent for change and a responder to change. Thus, changes in the environment, the examples of role models, and reinforcements can be used to promote healthier behaviour. This core construct is also central to social ecological models and more important today than ever before. Social ecological model The last conceptual model is the social ecological model, discussed earlier, which helps to understand factors affecting behaviour and also provides guidance for developing successful programmes through changes in various environments, including social, built, and policy environments. Social ecological models emphasize multiple levels of influence (such as individual, interpersonal, organizational, community, and public policy) and the idea that behaviours both shape and are shaped by social and other environments (McLeroy et al., 1988; Sallis et al., 2008). (p.208) The principles of social ecological models are consistent with social cognitive theory concepts that suggest that initially creating an environment conducive to change is important to make it easier to adopt healthy behaviours. Given the widespread problems of overnutrition in

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developed countries (and their increase in developing countries), more attention is being focused towards increasing the health-promoting features of communities and neighbourhoods and reducing the ubiquity of high-calorie, high-fat food choices (Glanz et al., 2005; Sallis & Glanz, 2009). Other theories This chapter has focused on use of health promotion and education theories to proactively improve eating and activity levels, as they are the key behavioural contributors to childhood obesity. Other theories may be brought to bear on the discussion in productive ways while not pointing directly to intervention strategies. For example, theories of deviance may be applied to the stigma that obese youths may encounter – a stigma that may have consequences on both mental and physical health (Puhl & Latner, 2007; Zabinski et al., 2003). Education about stigma for children and teachers can play a role in improving the social context for obesity prevention (Puhl & Latner, 2007) but it is not yet clear whether it is instrumental or mediating in actual prevention effects. As policy and environmental changes are brought to bear on healthy eating and physical activity, and hopefully reduce obesity prevalence over time, it will be important to examine the potential positive (e.g., social norm changes that motivate individuals to eat more healthy and be more active) and negative impacts (e.g., further stigmatization of overweight individuals).

Selecting an appropriate theoretical model or models Effective prevention depends on marshaling the most appropriate theory and practice strategies for a given situation (Glanz et al., 2008). Different theories are best suited to different populations and situations. For example, when attempting to focus on norms for sports participation among children and adolescents as a way to increase activity, the theory of planned behaviour may be useful. The stages of change model may be especially useful in developing interventions for children at high risk for diabetes if they are receiving medical care or counselling. When trying to teach children and their parents how to choose and prepare healthy foods, consumer information processing may be more suitable. The choice of the most fitting theory or theories should begin with identifying the problem, goal, and units of practice, not with simply selecting a theoretical framework because it is intriguing or familiar (Glanz et al., 2008). Health promotion experts should review the research literature periodically to supplement their first-hand experience and that of their colleagues. A central premise in applying an understanding of the influences on health behaviour to childhood obesity prevention is that one can gain an understanding of individuals and populations through interviews and surveys, enabling a better focus on that individual or group’s readiness, self-efficacy, knowledge level, and so on. Clearly, it is necessary to select a ‘short list’ of factors to evaluate, which can be guided by the theories and models described here. Those frameworks that you choose to apply should have both conceptual relevance and practical value (Glanz & Bishop, 2010). Such frameworks should also consider the context in which any intervention would take place. The integration of multiple theories into a comprehensive model tailored for a given individual or targeted to a specific community requires careful analysis of the audience and frequent reexamination during programme design and implementation. Similarly, from an international

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perspective, cultural fit will be important. For example, ideas that may be culturally acceptable in Japan (Glanz et al., 2009) might not resonate with American audiences. At the same time, new ideas that come from other cultural contexts should not be dismissed as they may broaden your (p.209) thinking about potentially successful strategies in your own country and its cultural and socioeconomic subgroups.

Applying theories to programme planning and using models from other public health problems Recently, influential reports such as the U.S. Institute of Medicine’s (IOM) Preventing Childhood Obesity: Health in the Balance (Koplan et al., 2005) have recommended that childhood obesity prevention should address multiple levels and multiple sectors. These authoritative recommendations are clearly consistent with an ecological perspective and with social cognitive theory constructs. The IOM report, for example, suggests immediate steps that include actions by Federal, state, and local governments; industry and media; health care providers; community organizations; schools; and families (Koplan et al., 2005). Recent follow-up recommendations from IOM and from the U.S. Centers for Disease Control highlight the perceived importance of the ecological perspective, by encouraging changes in the food and activity environments within local communities in order to prevent childhood obesity development (Centers for Disease Control, 2009; IOM, 2009). One example of a theory-based intervention for adolescent obesity prevention is the Dutch Obesity Intervention in Teenagers (NRG-DOiT) (Singh et al., 2006). The intervention was developed using intervention mapping (Bartholomew et al., 2006; Brug et al., 2005) to incorporate theory and evidence in the development of the programme. The programme aims to reduce intake of sugar-sweetened beverages (SSB), increase physical activity, and prevent or reduce weight. The intervention has both a classroom curriculum and environmental components, and draws on constructs from social cognitive theory, theory of planned behaviour, and other models, and includes multiple levels of intervention (Singh et al., 2006). The intervention was implemented with moderately high success (Singh et al., 2009a) and was effective in reducing skinfold thickness and consumption of sugar-sweetened beverages for up to 20 months (Singh et al., 2009b). However, there was no significant intervention effect on screenviewing behaviour, active commuting to school, or consumption of snacks (Singh et al., 2009b). Some experts have drawn direct comparisons between childhood obesity prevention strategies and several components of comprehensive tobacco control policies and programmes (Mercer et al., 2003). Indeed, tobacco control is one of the most remarkable public health success stories of the past century. The next chapter, by Eriksen and others, describes how some tobacco use prevention strategies might be applied to fight childhood obesity, though some types of legal, policy, and communication approaches do not translate easily or directly to the obesity issue. These ideas are provocative and warrant close scrutiny, despite some legal and regulatory tenets that differ for food than for tobacco products in the United States and other countries. It is important to bear in mind some basic differences between obesity-related behaviours (eating and activity) and tobacco use: first, there is no need for use of any tobacco products and a goal of ‘zero consumption’ is an appropriate health goal for youth smoking. The same cannot be said of food, which is necessary for survival even though lower food intake may be an important goal.

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Obesity prevention recommendations regarding activity are to increase, rather than decrease, active recreation and transport behaviours. Second, health-enhancing dietary changes require qualitative change, not just modification of the amount of food consumed, and increases in activity can take many different forms as well (not just a simple ‘increase’). Third, the act of making dietary changes and monitoring those changes – often tasks relegated to parents – require accurate knowledge about the nutrient composition of foods or a convenient, practical reference source. Thus, information acquisition and processing (p.210) may be more complex for dietary change than for changes in some other health behaviours, such as smoking and exercise. Because of this, consumer information processing models (described earlier) are more important for nutrition intervention than for health related behaviours like tobacco use avoidance. Other important issues including longterm maintenance of healthy eating and activity patterns, the format and medium for providing dietary advice, nutritional adequacy, options for initiating the change process, and the changing food supply, are distinct from the key issues related to tobacco control.

Challenges and opportunities Childhood obesity has complex and multilevel etiology and thus requires thoughtful and varied approaches to prevention. Regardless of the prevention strategies attempted, they are best implemented and evaluated (as all should be) if based on theoretical models or at least specific aspects of various theoretical models. It is clear that childhood obesity, like many other complex phenomena, will require multiple prevention strategies that should be informed by theoretical models from various disciplines. This adds additional complexity because some disciplines and their theoretical models that need to be brought to bear don’t necessarily focus on individual behaviours or the change in individual behaviours, but rather focus on larger systems changes (e.g., food production systems). Thus, it will be important to figure out how different theoretical models fit together at different levels within the social ecological model in order to ultimately impact individuals’ eating and activity behaviours. This can be most successful if a continuing dialogue is maintained between policy makers, practitioners developing action-oriented interventions, and researchers and health promotion/behaviour change planners. References Bibliography references: Ajzen, I. (1991) The theory of planned behavior. Organizational Behavior and Human Decision Making Processes 50, 179–211. Ammerman, A.S., Lindquist, C.H., Lohr, K.N., & Hersey, J. (2002) The efficacy of behavioral interventions to modify dietary fat and fruit and vegetable intake: a review of the evidence. Preventive Medicine 35, 25–41. Bandura, A. (1986) Social foundations of thought and action: a social cognitive theory, PrenticeHall, Englewood Cliffs, NJ. Bandura, A. (1997) Self-efficacy: the exercise of control. W.H. Freeman and Company, New York, NY.

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Bartholomew, L.K., Parcel, G.S., Kok, G., & Gottlieb, N.H. (2006) Planning health promotion programs: an intervention mapping approach, Jossey-Bass, San Francisco. Brug, J., Oenema, A., & Ferriera, I. (2005) Theory, evidence and intervention mapping to improve behavior nutrition and physical activity interventions. International Journal of Behavioral Nutrition and Physical Activity 2, 2. Centers for Disease Control and Prevention. (2009) Recommended community strategies and measurements to prevent obesity in the United States. MMWR 58(RR-7), 1–29. Gehling, R.K., Magarey, A.M., & Daniels, L.A. (2004) Food-based recommendations to reduce fat intake: an evidence-based approach to the development of a family-focused child weight management programme. Journal of Paediatrics and Child Health 41, 112–118. Glanz, K. (1997) Behavioral research contributions and needs in cancer prevention and control: dietary change. Preventive Medicine 26, S43–S55. Glanz, K. & Bishop, D.B. (2010) The role of behavioral science theory in development and implementation of public health interventions. Annual Review of Public Health 31, 399–418. Glanz, K. & Rimer, B.K. (1995) Theory at a glance: a guide to health promotion practice. Bethesda, MD: National Cancer Institute. 2nd edition 2005. NIH Publ. 05-3896. Glanz, K. & Rudd, J. (1993) Views of theory, research, and practice: a survey of nutrition education and consumer behavior professionals. Journal of Nutrition Education 25, 269–273. Glanz, K., Lewis, F.M., & Rimer, B.K. (Eds.) (1990) Health Behavior and Health Education: Theory, Research, and Practice. Jossey-Bass, Inc., San Francisco. Glanz, K., Owen, N., & Wold, J.A. (2009) Perspectives on behavioral sciences research for disease prevention and control in populations. Journal of the National Institute of Public Health (Japan), 58, 40–50. Glanz, K., Rimer, B.K., & Lewis, F.M. (Ed.) (2002) Health behavior and health education: theory, research and practice (3rd edition). Jossey-Bass Inc., Publishers, San Francisco. Glanz, K., Rimer, B.K., & Viswanath, K. (Ed.) (2008) Health behavior and health education: theory, research, and practice (4th edition). Jossey-Bass, San Francisco. Glanz, K., Sallis, J.F., Saelens, B.E., & Frank, L.D. (2005) Healthy nutrition environments: concepts and measures. American Journal of Health Promotion 19, 330–333. Green, L.W. & Kreuter, M.W. (2005) Health promotion planning: an educational and ecological approach (4th edition). McGraw-Hill, New York. Institute of Medicine (2009) Local government actions to prevent childhood obesity. National Academy Press, Washington, DC.

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Kok, G., Gottlieb, N.H., Commers, M., & Smerecnik, C. (2008) The ecological approach in health promotion programs: a decade later. American Journal of Health Promotion 22, 437–442. Koplan, J.P., Liverman, C.T., & Kraak, V.I. (Ed.) (2005) Preventing childhood obesity: health in the balance, National Academy Press, Washington, D.C. Kumanyika, S., Van Horn, L., Bowen, D., et al. (2000) Maintenance of dietary behavior change. Health Psychology 19, (Suppl 1) 42–56. Legler, J., Meissner, H.I., Coyne, C., Breen, N., Chollette, V., & Rimer, B.K. (2002) The effectiveness of interventions to promote mammography among women with historically lower rates of screening. Cancer Epidemiology Biomarkers and Prevention 11, 59–71. Marcus, B.H., Dubbert, P.M., Forsyth, L.H., et al. (2000) Physical activity behavior change: issues in adoption and maintenance. Health Psychology 19 (Suppl 1), 32–41. McLeroy, K., Bibeau, D., Steckler, A., & Glanz, K. (1988) An ecological perspective on health promotion programs. Health Education Quarterly 15, 351–377. Mercer, S.L., Green, L.W., Rosenthal, A.C., Hustern, C.G., Khan, L.K., & Dietz, W.H. (2003) Possible lessons from the tobacco experience for obesity control. American Journal of Clinical Nutrition 77 (suppl), 1073S–1082S. Montaño, D.E. & Kasprzyk, D. (2002) The theory of reasoned action and the theory of planned behavior. In K. Glanz, B.K. Rimer, & F.M. Lewis (Ed.), Health behavior and health education: theory, research, and practice, 3rd edition, pp. 67–98, San Francisco, CA: Jossey-Bass, Inc. Noar, S.M., Benac, C.N., & Harris, M.S. (2007) Does tailoring matter? Meta-analytic review of tailored print health behavior change interventions. Psychological Bulletin 133, 673–693. Prochaska, J.O., DiClemente, C.C., & Norcross, J. (1992) In search of how people change: applications to addictive behaviors. American Psychology 47, 1102–1114. Prochaska, J.O., Redding, C., & Evers, K. (2008) The transtheoretical model of behavior change. In K. Glanz, B.K. Rimer, & K. Viswanath (Ed.) Health behavior and health education: theory, research, and practice (4th edition), pp. 97–121. San Francisco, CA: Jossey-Bass, Inc. Puhl, R.M. & Latner, J.D. (2007) Stigma, obesity, and the health of the nation’s children. Psychology Bulletin 133, 557–580. Rudd, J. & Glanz, K. (1990) How consumers use information for health action: consumer information processing. In K. Glanz, F.M. Lewis, & B.K. Rimer (Ed.) Health behavior and health education: theory, research, and practice, pp. 115–139. San Francisco, CA: Jossey-Bass, Inc. Sallis, J.F, & Glanz, K. (2009) Physical activity and food environments: solutions to the obesity epidemic. The Milbank Quarterly 87, 123–154.

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Sallis, J., Owen, N., & Fisher, E.G. (2008) Ecological models of health behavior. In K. Glanz, B.K. Rimer, & K. Viswanath (Ed.) Health behavior and health education: theory, research, and practice (4th edition), pp. 464–485. San Francisco, CA: Jossey-Bass, Inc. Singh, A.S., Chin Paw, M.J.M., Brug, J., & van Mechelen, W. (2009a) Process evaluation of a school-based weight gain prevention program: the Dutch Obesity Intervention in Teenagers (DOiT). Health Education Research 24, 772–777. Singh, A.S., Chin Paw, M.J.M., Brug, J., & van Mechelen, W. (2009b) Dutch Obesity Intervention in Teenagers: effectiveness of a school-based program on body composition and behavior. Archives of Pediatrics and Adolescent Medicine 163, 309–317. Singh, A.S., Chin Paw, M.J.M., Kremers, S.P.J., et al. (2006) Design of the Dutch Obesity Intervention in Teenagers (NRG-DOiT): systematic development, implementation and evaluation of a school-based intervention aimed at the prevention of excessive weight gain in adolescents. BMC Public Health 6, 304. Smedley, B.D. & Syme, S.L. (Ed.) (2000) Promotion Health: Intervention Strategies from Social and Behavioral Research. National Academy Press, Washington, DC. Zabinski, M.F., Saelens, B.E., Stein, R.I., Hayden-Wade, H.A., & Wilfley, D.E. (2003) Overweight children’s barriers to and support for physical activity. Obesity Research 11, 238–246.

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University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

The application of public health lessons to childhood obesity prevention Michael Eriksen Rodney Lyn Barbara J. Moore

DOI:10.1093/acprof:oso/9780199572915.003.0019

Abstract and Keywords There is no shortage of theories, models, and approaches to help guide public health program planning in relation to the prevention of childhood obesity. This chapter does not propose a comprehensive intervention program for childhood obesity, but rather identifies factors associated with success in other public health areas, both as a result of planned and unplanned interventions. It reviews six factors that may be relevant in preventing childhood obesity. These include the information environment (e.g., marketing, advertising, warning labels, ingredient disclosure, and labeling); access and opportunity (e.g., availability in local stores and schools); economic factors (e.g., taxes); the legal and regulatory environment (e.g., restrictions on public sales, laws, food fortification); and prevention and treatment programs and the social environment (e.g. changing social norms).

Keywords: education, health promotion, health education, obesity, prevention, intervention, program, planning, marketing, advertising

Chapter summary There is no shortage of theories, models, and approaches to help guide public health programme planning in relation to the prevention of childhood obesity. The purpose of this chapter is not to propose a comprehensive intervention programme for childhood obesity, but rather to identify factors associated with success in other public health areas, as a result of both planned and unplanned interventions. This chapter reviews six factors that may have relevance for the prevention of childhood obesity. These include the information environment (e.g. marketing, advertising, warning labels, ingredient disclosure, and labelling); access and opportunity (e.g.

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availability in local stores and schools); economic factors (e.g. taxes); the legal and regulatory environment (e.g. restrictions on public sales, laws, food fortification); prevention and treatment programmes; and the social environment (e.g. changing social norms).

Public health lessons learned There is an increasing interest in comprehensive public health interventions that strike a balance between efforts directed at the individual and efforts directed towards changing the social environment in which people live. It is likely that this approach will be as relevant for the prevention and remediation of childhood obesity, as it is for other contemporary public health challenges. Drawing upon the tobacco control framework as well as other public health efforts, we propose six factors that have promise in addressing public health problems having commercial dimensions, or which are politically sensitive (e.g., tobacco, underage alcohol consumption, injury prevention, etc.). These six factors are: 1 The information environment 2 Access and opportunity 3 Economic factors 4 The legal and regulatory environment 5 Prevention and treatment programmes 6 The social environment The information environment The environment in which people are informed about public health issues is not only of critical importance, but also fraught with controversy, particularly when dealing with the marketing of commercial products. As a rule, the public health community tends to favour restrictions on commercial speech, if thought necessary to ensure the public health. On the other hand, some (p.214) commercial interests insist that any restrictions on marketing are infringements of their right to communicate. A thorough discussion on individual speech versus commercial speech is beyond the scope of this chapter, but was central to the debate in the United States regarding the Food and Drug Administration’s efforts to regulate tobacco products (Curfman et al., 2009; Kessler, 2001), as well as in more recent attempts to restrict advertising for alcohol and foods. A few elements of free speech are briefly discussed here: Marketing and advertising

Although product advertising may result in a public health benefit when the advertising promotes healthful products, (Ippolito & Mathios, 1995) the majority of the debate about product marketing focuses around those products that may have harmful effects, particularly among children. Governments have the right to alter the informational environment, particularly when the information being conveyed is considered to be false, misleading, or deceptive. In the United States, the regulatory authority in this area is shared by multiple Federal agencies, but particularly by the Food and Drug Administration and the Federal Trade Commission. Gostin (2004) notes that the government’s power to alter the informational environment is one of the major ways governments can ‘assure the conditions for people to be healthy’. This can be

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achieved by sponsoring health education campaigns requiring product labelling, and restricting harmful or misleading advertising. Here again, the lessons from tobacco control inform the childhood obesity debate. The discovery that very young children were more likely to recognize Joe Camel than Mickey Mouse, and that adolescents were much more likely than adults to smoke the most advertised brands, led regulators to attempt to restrict the information environment, particularly as it relates to young people (Kessler, 2001). This effort continues, typically through litigation, as evidenced by the U.S. Federal Court ruling that tobacco advertising needed to be restricted to black and white text only and the misleading terms such as ‘Light’ and ‘Mild’ needed to be banned (U.S. Department of Justice v. Philip Morris et al., 2006). This ruling has been appealed by both the tobacco and advertising industries and is headed to the U.S. Supreme Court. There is good evidence that the advertising and marketing of food products influences parental and child food choice (Food Standards Agency, 2003). The Institute of Medicine (2006) has concluded that advertisements shape the product preferences and eating habits of children. Moreover, their findings indicate that children under the age of 8 years are generally unable to understand the persuasive intent of advertising. Additional empirical studies clearly document parents’ underestimation of their children’s television and media exposure (Hersey & Jordan, 2007), the wide range of food advertising techniques the channels use to reach children and adolescents (Story & French, 2004), the overexposure of children to food and beverage advertisements on certain television channels (Outley & Taddese, 2006), the increase in the number of television commercials viewed by children (Kunkel, 2001), the increase in ads for high fat and high sodium convenience foods (Gamble & Cotugna, 1999), the increased risk of overweight associated with excessive television viewing (Lumeng et al., 2006; Epstien et al., 2008), the effect of even brief exposure to television commercials on food preferences of young children (Borzekowski & Robinson, 2001), and an association between television viewing and the consumption of fast foods (Wiecha et al., 2006; French et al., 2001). However, two studies by Powell and colleagues (2007) and the Federal Trade Commission (2007) found that children’s exposure to TV food advertising has not increased between the 1970s and 2004. The FTC study did find that the mix of food advertisements has shifted, so that restaurant, fast food, and snacks advertisements are at a higher level than observed in 1977. The FTC report also found that advertisements for sedentary pursuits (e.g. TV programming, screen and audio entertainment) have shown a marked increase between 1977 and 2004, and these findings continue to fuel the debate about what is causing childhood obesity. (p.215) The Kaiser Family Foundation (2004) reviewed the evidence on the effect of all types of media on children’s dietary behaviour, and recommended the reduction or regulation of food ads targeted at children, among other policy options. The American Psychological Association (2004) concluded that televised advertising messages can lead to unhealthy eating habits, particularly for children under 8 years of age who are unable to distinguish advertising from programming and lack the skills and comprehension to critically evaluate advertised messages. Currently, there are no legal restrictions on the marketing of calorie-dense, low nutritional quality food to children. Some consider it to be ‘open season’ on children, with cartoon characters, celebrities, promotional tie-ins, product placement, sponsorship, games, and toys all

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being used to market unhealthy foods to children. None of these strategies is still used to promote tobacco products to children, mainly because it is illegal to sell tobacco products to minors; some states prohibit the under-age use and possession of tobacco products, and the tobacco companies themselves have either voluntarily agreed not to market to children, or have been prohibited from doing so as a result of the settlement of legal proceedings. There is good evidence to suggest that restrictions on the advertising of unhealthy foods, the promotion of healthy choices, and possibly paid counter-advertising campaigns will improve the information environment to stem childhood obesity. Warning labels, ingredient disclosure, and labelling

As part of enabling the public to be informed consumers, public health experts call for the full disclosure of nutrition information. Commercially purchased food products currently have nutrition labels, which list ingredients used in the food product, as well as nutrition information on calories, fat, and other nutritional parameters. The nutrition label presents calories for one ‘serving’ rather than for the entire contents of the package, even if consumption of the entire package is typical. Examples are bottled sweetened teas, sodas, or coffee drinks that may deliver 150 calories per serving, but few people notice that each bottle contains 2.5 servings. Foods purchased in restaurants and fast food establishments have undergone ‘Supersizing’ over the past decades (Nestle, 2003). Calorie and fat information per serving on restaurant menu boards or on menus is neither widely required by law nor typically offered. Warning labels have been required on cigarette packages since the late 1960s; however, U.S. warning labels have not kept pace with international standards and are generally not noticed by smokers. Currently, there are no warning labels for food products, other than alcohol-containing products, and in some instances, for certain food products that may pose a high risk of infectious disease (e.g. uncooked shellfish). The Report of the American Psychological Association (2004) on the effect of advertising on children concluded that any warnings, disclosures, or disclaimers about products advertised to children be communicated in clear language comprehensible to the intended audience. Acknowledging that a comprehensive national plan was needed to stem obesity in England, in January 2008, the British Prime Minister, Gordon Brown, announced a multidimensional plan (Cross-Government Unit, 2008) to reverse levels of obesity. Although concerned about obesity in persons of all ages, the plan starts with a major focus on reducing levels of childhood obesity in England to those that prevailed in 2000, and accomplishing this reversal by the year 2020. Specifically to curb obesity and guide consumer food choices, the English programme is planning to use a traffic light system to rank foods. This system is aimed at encouraging the consumption of certain foods that are low in energy density and high in nutrient delivery and discourage consumption of foods that are high in fat, saturated fat, sodium, and sugar (CrossGovernment Unit, 2008). In the United States, Hannaford Brothers grocery stores and other organizations are currently using or planning to use a system of labelling foods based on their nutritional content. (p.216) The Hannaford system rates foods based on nutritional parameters and assign zero stars to foods not meeting their pre-set criteria, one star for foods that do a reasonably good job of matching the criteria, two stars for foods that do a better job of matching, and three stars for those that most closely match the criteria (Hannaford Guiding Stars Program, n.d.). Although the Hannaford system has not, to our knowledge, been formally

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evaluated to measure the effect of the stars on consumer choices, it is possible that foods with more stars will be selected and foods with zero stars will be avoided. This remains an area of potentially useful research as we learn how such systems guide consumer choices and product sales, but it must be remembered that one food product is not eaten individually, but is a component of a complete diet and that the total daily caloric intake is what is of importance. Ultimately, the effects of such information systems on food consumption and body weight will need to be evaluated. Access and opportunity Ease of access, the ubiquitous availability, and ready opportunity to purchase foods with high sugar, fat, and sodium content likely contribute to the increase in the prevalence of overweight and obesity in the United States and other developed countries. Although empirical evidence on the precise contribution to childhood obesity of easy availability and access to certain types of food and beverage products is debated (Vartanian et al., 2007), some restrictions on access for children, especially in schools, are being implemented on an ad hoc basis. To the extent that such efforts are evaluated, they may help establish a foundation for subsequent public health interventions for obesity prevention and remediation. The community environment

Community access to food and beverage products is ubiquitous and efforts to restrict access to foods judged to be unwholesome may well be informed by the tobacco experience. Because the sale, and frequently the possession, of tobacco products by minors are illegal, various usereduction efforts have focused on enforcing tobacco access restrictions. Federal legislation has been promulgated to require states to enforce a prohibition on the sale of tobacco products to minors, and some stores voluntarily restrict access to tobacco products by keeping inventory behind the counter, and requiring a personal interaction between the sales clerk and the customer to obtain the product. However, the evidence about the effectiveness of enforcement of minors’ access laws in reducing the use of tobacco products is unclear (Warner et al., 2003). Increasingly, minors have used other means (shoplifting, purchasing by friends, social acquisition) to obtain cigarettes. Whether these restrictions are effective by themselves, enforcement of laws to prevent the sale of tobacco products to minors sends a strong and consistent message on the hazard of tobacco use and should be considered a necessary, but not necessarily sufficient, action to reduce adolescent tobacco use. Regarding calorie-dense, low nutritional quality foods, there is no restriction whatsoever on their retail and commercial availability. As is the case with cigarettes, these snack and fast food products are readily available, in vending machines, gas stations, convenience stores, etc. In fact, nearly every retail and commercial outlet sells gums, candies, crackers, cookies, and soft drinks. However, reviewing the literature on the influence of availability on food choices, French and colleagues (1997) concluded that the relationship is inconsistent, particularly compared to the strong inverse relationship between price and consumption. Further research is needed to determine if restricting commercial access and availability would be effective in reducing the consumption of calorie-dense and low nutritional quality foods. As long as these products can legally be sold to minors, it is unlikely that widespread restriction of access to these products is feasible, and even if feasible, unlikely to have a public health effect.

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(p.217) The school environment

Schools are an important setting to encourage health-promoting behaviours, including the prevention of obesity (Hersey & Jordan, 2007). Centers for Disease Control and Prevention (CDC) (1994) has issued guidelines for schools to prevent nicotine addiction that include smokefree policies, tobacco prevention policies, and smoking cessation assistance for teachers, staff, and students. Similar guidelines exist for nutrition and physical activity programmes in schools (Centers for Disease Control and Prevention, 1996). There is some scientific evidence that manipulation of the school cafeteria and physical activity environment can improve the cardiovascular health of elementary school children (Wechsler et al., 2000). The literature in this area indicates that school-based interventions have produced healthful food choices among students, increased student knowledge and attitudes about physical activity and nutrition (Institute of Medicine, 2005), increased physical activity (Budd & Volpe, 2006), and reduced energy intake, fat intake, and sedentary behaviours (Caballero, 2004). However, the presence of vending machines, concerns about cafeteria menus, the declining requirement for physical education in U.S. schools, and the lack of safe routes to school for walking or biking suggest that the school environment and the surrounding community will be a vitally important setting in which to address childhood obesity. The United States Congress has mandated that local boards of education establish local wellness policies (Child Nutrition and WIC reauthorization, 2004). The IOM has developed nutrition standards for foods in schools (Institute of Medicine, 2007b). The American Public Health Association (2003) has called for the development of school policies for the promotion of healthful eating environments and the prohibition of sales of soft drinks and other foods of low nutritional value during the school day. The American Academy of Pediatrics (2004) has called for school policies that restrict the sale of soft drinks. There has been some progress in establishing healthier school environments as school districts nationwide are implementing wellness policies, though consistency across districts has been limited. CDC recently reported progress in school nutrition services practices between 2000 and 2006 (O’Toole et al., 2007). In 2006, the American Beverage Association (ABA) announced a voluntary policy that is intended to phase out the sale of full-calorie soft drinks in schools by 2009–2010 school year. According to the ABA’s 2006 progress report, 35% of schools implemented the voluntary guidelines in the first year (American Beverage Association, 2007). In 2007, the Robert Wood Johnson Foundation announced a $500 billion commitment to mitigating childhood obesity by the year 2015 (http://www.reversechildhoodobesity.org, n.d.). This initiative is focused on both policy and environmental change and may have an impact on the school environment. Economic factors In addition to its potential for altering the informational environment, the government’s power to tax and spend is one of the major ways in which it can assure the conditions for people to be healthy. The power to levy taxes can be leveraged to provide incentives to engage in healthy behaviours, and disincentives to practise risky ones, but these taxes can also be inequitable and regressive.

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Taxes, behaviour, and public health

Most of the public health experience with manipulating economic factors to encourage healthy behaviours or to discourage risky behaviours has been related to excise tax policy on products like tobacco, gasoline, and alcohol. Because of the popularity of increasing tobacco taxes as a public (p.218) health strategy and the parallels that are frequently drawn between tobacco tax policy and a possible similar tax scheme for certain foods and beverages, the following section highlights some of the specific aspects of the taxation of tobacco products. Tobacco products, like most consumer products, have been shown to be price-sensitive, that is, as price increases, consumption decreases. Children have been shown to be most price sensitive, with an approximate 7% decrease in consumption for every 10% increase in price (U.S. Department of Health and Human Services, 2000). As a result of this well-established price elasticity, excise tax increases on tobacco products have been a common and popular way to reduce adolescent tobacco use, and to increase much-needed state revenue. In 2008–2009, nearly half the states increased their excise tax on tobacco products (Campaign for Tobacco Free Kids, 2009). Some states have earmarked or dedicated a portion of the excise tax increase for tobacco prevention or health promotion programmes. Revenues raised through this mechanism could also be earmarked for childhood obesity prevention programmes. It is likely that applying the same strategy to calorie-dense foods of minimal nutrition value would have the same effect as seen for tobacco, i.e., as price increases, consumption falls. The World Health Organization has indicated its support for taxes that shape food purchasing patterns (http://www.who.int/dietphysicalactivity/faq/en/index.html). However, it has proven more difficult to tax foods and beverages than tobacco products. Boehmer et al. (2007) found that soda and snack tax legislation was introduced 49 times by state legislatures between 2003 and 2005, but none was enacted. Trust for America’s Health (2007) reported that 17 states and the District of Columbia had a soda or snack tax. Jacobson and Brownell (2000) suggest that to avoid the possible negative reaction to levying large excise taxes on soft drinks and snack foods, municipalities consider small tax increases, and that the proceeds from these increases be used to fund health promotion programmes, including subsidizing the availability of healthier food choices. In addition to considering excise taxes on calorie-dense foods of minimal nutritional value, incentives or subsidies to make fruits and vegetables more available and affordable could be considered. French and colleagues (1997) reviewed the literature on the relationship between price and consumption of fruits and vegetables, and found a consistent pattern, namely that lower prices are associated with higher consumption. In their own empirical work, these researchers found this same pattern among adolescents and found it to be robust across different age groups and food types. The legal and regulatory environment Laws and regulations have become increasingly prominent and effective in improving the public health. Public health law has emerged as a strategic element in planning public health interventions (Goodman et al., 2003), and the Institute of Medicine has identified law and policy as one of the eight emerging themes for the future of public health training (Institute of Medicine, 2002). Laws and regulations seem to be one of the few common themes spanning

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multiple reports from the Ten Greatest Achievements in Public Health (Ward & Warren, 2007) to the Guide to Community Preventive Services (Hersey & Jordan, 2007) and they also appear to be an essential factor in successful health-related social movements. The following section discusses the importance of laws, regulations, and litigation. Laws

Laws have played a critical role in the achievement of many public health accomplishments in the 20th century. Mensah and his colleagues (2004) review the use of law as a tool for preventing chronic disease and reducing injury. Their wide-ranging analysis covers topics such as bans or restrictions on public smoking, laws on blood alcohol concentration, food fortification, and the Framework Convention for Tobacco Control. (p.219) With respect to laws related to preventing obesity or childhood obesity, there is little Federal legislation. Because of the lack of engagement or lack of will to address obesity and strong interest in protecting the food, beverage, and restaurant industries on the part of Federal legislators, most of the regulatory legislative initiatives have occurred at the state level. The legislative process is often a difficult avenue for advancing measures intended to protect or promote the public health, especially if consensus among legislators cannot be achieved. Rather than attempt to resolve the details of its childhood obesity legislation in chamber, the State of Arkansas’ legislature empowered a 15-member statewide Child Health Advisory Council to review existing evidence, balance competing interests, and make binding recommendations directly to the Arkansas State Board of Education (Ryan et al., 2006). Other states have established similar councils, committees, and task forces to develop plans and oversee efforts to address obesity treatment in adults (Michigan State Guidelines, n.d.) or to prevent childhood obesity (Boehmer et al., 2007). Regulation

Legislation often results in administrative actions to regulate products that might have an adverse effect on the public health. There does not appear to be a clear relationship between potential harm from products and the level of regulation. For example, food products are relatively tightly regulated, particularly by the Food and Drug Administration as a result of the authority contained in the Food, Drug, and Cosmetic Act. Although there has been substantial progress in reducing tobacco use, tobacco products continue to be relatively unregulated, despite the protestations of the tobacco industry to the contrary (Eriksen & Green, 2009). The 1990s saw unprecedented efforts to regulate tobacco products, with the Food and Drug Administration (FDA), under the direction of the President, exerting jurisdiction over tobacco products, only to be rebuffed by the Supreme Court, which ruled that Congress has not provided the FDA the explicit authority to regulate tobacco products (Food and Drug Administration, 2000). Meaningful FDA regulation of tobacco products was not promulgated until 2009 and is on appeal to the Supreme Court (Curfman et al., 2009). Food products, on the other hand, come under FDA authority and are clearly regulated in terms of certain aspects of health and safety, including nutrition labelling and health claims. However, FDA does not currently regulate the nutritional content of food products, portion size, or marketing strategies. Currently, if a food product were to make an unjustified health claim, the

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FDA could act. Similarly, if the advertising were deemed to be false, misleading, or deceptive, the Federal Trade Commission (FTC) could take action. However, concerns of health experts about product marketing are not necessarily focused on health claims or deception, but on the appeal to children of calorie-dense foods and beverages of minimal nutrition value. So, it is unlikely that traditional FDA or FTC authority would help in the area of greatest concern with marketing food products to children that are deemed unhealthful. If governmental regulation is not likely or possible, mandatory industry standards could be considered to guide minimum nutrient content, portion size, and marketing of products targeted to children. Industry self- or voluntary regulation is less likely to be effective (Mello et al., 2007). Yet, such regulations represent the majority of new regulations related to food marketing to young people (Hawkes, 2007). In addition to Federal regulation, local authorities also have the ability to regulate food products, particularly in the areas of licensing, sampling, zoning restrictions, land use (Ashe et al., 2003), and conditional use permits (Bolen & Kline, 2003). Local restrictions on advertising may be more difficult in light of First Amendment considerations and free speech. Local efforts to regulate tobacco ads have often been stymied because of Federal preemptive legislation. The same preemption of local authority may not exist for local control (p.220) over innovative strategies designed to limit sale of calorie-dense foods of minimal nutrition value. Litigation

In addition to laws and regulation, litigation has recently become a powerful tool in preventing product-related injuries and assuring the public health in such areas as tobacco, gun violence, and lead paint. Vernick and colleagues (2003) and Parmet and Daynard (2000) concluded that litigation can deter dangerous activities and contribute to the public health. Others argue that product liability litigation has unacceptable social costs and may diminish the role of personal responsibility. For tobacco control, the 1990s were the era of tobacco litigation. A myriad of individual, class action, and state Attorney General suits transformed the tobacco control environment and resulted in lasting change in the way tobacco products are marketed and how the public views tobacco companies. The Master Settlement Agreement of November 1998 required the participating tobacco companies to agree to restrict certain marketing practices, disband trade associations, reform their corporate behaviour, and provide hundreds of billions of dollars to settling states over the next 25 years (Schroeder, 2004). In addition to significant financial penalties, tobacco litigation in the 1990s also resulted in an unprecedented level of tobacco industry document disclosure that has served as a treasure trove for scholarly research and, perhaps most importantly, changed the social-normative opinion of the general public towards tobacco companies (Bero, 2003). With respect to food-related litigation, there have been some attempts to sue fast food restaurants as being at least partially responsible for the obesity of the youthful plaintiffs, and for other reasons, such as consumer safety (e.g. excessive temperature of coffee resulting in customer harm). To date, these efforts have been less than successful, but are widely seen as the vanguard of future litigation efforts (Mello et al., 2003). In fact, attorneys experienced in

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tobacco litigation recently sponsored a conference to develop strategies and resources to direct individual and class action efforts towards the problem of obesity. At this point, it is not clear whether these efforts will follow the tobacco model and be successful in obtaining settlements or court victories. Prevention strategies This analysis would be incomplete without a consideration of the strong and direct role played by individual efforts and planned interventions to improve health behaviours. The impact of specific interventions on public health success stories is described earlier in this chapter, and it is not the intent here to review the literature on the quality of the scientific evidence for changing dietary behaviours or physical activity, but rather to highlight lessons from other public health areas that may have some utility for multiple health problems, and may be generalizable to preventing obesity. School-based interventions

As previously discussed, school-based programmes appear to have robust and generalizable benefits for a number of public health programmes, including oral health, motor vehicle safety, and tobacco control. With respect to tobacco use prevention programmes, there is evidence that they are effective, especially those that have been conducted in coordination with comprehensive community and mass media prevention programmes (Jago & Baranowski, 2004). It is possible that school-based nutrition and physical activity programmes could be more effective in preventing childhood obesity than school tobacco programmes are in reducing tobacco use (Dietz & Gortmaker, 2001), although the IOM report on childhood obesity prevention (2005) (p.221) reported little success with school-based interventions in reducing BMI, there was some reported success in increasing physical activity and reducing TV use. The English programme to stem obesity (Cross-Government Obesity Unit, n.d.) aims to strengthen the nutrition and physical activity behaviours that are a normal part of every school day and will be instituting mandatory cooking courses for all middle school students by 2011. This is but one of many public health approaches that could be fairly easily adopted and implemented. Vending machine policies, school breakfast and lunch programmes, and required physical activity programmes are all significant components of childhood obesity prevention programmes where schools can play a constructive role. Media campaigns

Mass media efforts that build on sophisticated marketing approaches is a potentially effective way to improve dietary behaviour and increase physical activity levels among young people and adults. In tobacco control, themes of tobacco industry manipulation, the health effects of involuntary smoking on nonsmokers, and graphic depictions of the harm of smoking among real people have proven to be effective (Hersey et al., 2004; Sowden & Arblaster, 2004). The U.S. Government has made preliminary efforts to promote healthy eating and physical activity. Through the National Cancer Institute they launched the 5-A-Day programme to promote consumption of fruits and vegetables, a programme that is now run through the CDC. The government also funds provision of fruits and vegetables in pilot school systems throughout the United States (U.S. Department of Agriculture, 2005). These strategies have thus far failed to produce increased consumption of fruits and vegetables in that no state has met the Healthy

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People 2010 objectives for fruit and vegetable consumption (Centers for Disease Control and Prevention, 2007) but the USDA pilot programme may be expanded to more schools if funding permits and if results support continued support. In the arena of physical activity, the CDC launched the VERB campaign to promote physical activity of ‘tweens’, children between the ages of 9 and 13 (Huhman et al., 2005). One-year results from VERB showed positive results. Effectively, the campaign reached the majority of its target audience and youth exposed to the campaign were found to participate in more free-time physical activity than youth nationally (Huhman et al., 2005). It remains to be seen whether or not these findings can be replicated and if the programme will be re-funded. Despite the difficulties of achieving sustained weight loss, serious investment in populationbased strategies to improve the environment in schools, communities, and worksites is already underway. These changes are being promoted and supported by innovative new policies and programmes being pursued at the community and state level largely as a consequence of CDC funding to states for worksite wellness programmes: the USDA TEAM nutrition programme in schools, the Department of Transportation’s Safe Routes To School funding, and so on. The changes in these venues and other places where people live and work are focused on making the right choice (healthy eating and physical activity) the easy choice and are precisely the kinds of changes needed to make sustained weight loss and prevention of weight gain more likely to be achieved. The social environment The social environment – the way in which citizens, communities, the private sector, and governments interact to create norms and expectations – is a subtle but essential dimension of health-related social movements. Concern about the increase in alcohol-related motor vehicle fatalities created an environment receptive to increases in public involvement and supportive of public policies to reduce the harm caused by alcohol-impaired driving (Dejong & Hingson, 1998; (p.222) Shults et al., 2001). The popularity of designated drivers, minimum legal drinking age, blood alcohol concentration laws, community traffic safety programmes, and other interventions are a direct result of changing social norms. The desire of nonsmokers to be protected from exposure to secondhand smoke is a critical element in changing the tobacco control environment and reflects fundamental changes in how smoking is perceived in society today as compared to the 1960s when the Surgeon General’s report on smoking was published. As a result of advocacy for nonsmokers’ rights, most workplaces are smoke free, serum cotinine levels have been reduced by nearly 75% in the last decade (NHANES, 2009), and the social norms associated with smoking have been permanently changed. It is not clear, however, that the prevention of childhood obesity has an external dimension, or externality, that can serve as a parallel to nonsmokers’ exposure to secondhand smoke. One external factor worth considering is health care costs and the explosive yearly double-digit increases in the cost of health insurance. As health care costs escalate and insurance premiums increase steadily year after year, it is argued that the higher insurance rates paid by normal weight persons, to cover the higher costs of diseases and disability incurred by obese persons, is unfair. Several studies show that health care costs of obese persons are 25–35% higher than those of normal weight persons

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(Quesenberry et al., 1998; Wang et al., 2003). One study (Wee et al., 2005) showed that the health care costs of the morbidly obese are higher still. Some are suggesting that obese individuals should pay higher insurance rates the same way that smokers currently pay higher insurance rates because of their smoking habits. Another example is the higher rates paid for auto insurance by men or sports car owners or persons with speeding tickets. To address obesity, ‘incentivized health programmes’ are being launched by some insurers offering reduced deductibles to people who maintain a low BMI and take yearly physicals (Cordell, 2008). Innovative approaches are also being sought by worksites and large employers who manage insurance programmes for their employees (Goetzel et al., 2007). Another factor is the growing prevalence of childhood obesity and the consequent rise in pediatric illness. This is triggering public involvement in efforts to change the social environment and highlighting the need for collective action. Given the rapid increase in the prevalence of childhood obesity, the ‘visibility’ of the problem, and the seriousness of the problem for affected individuals, social and normative change is already beginning to occur (Institute of Medicine, 2007a). Collaborative approaches to preventing obesity are under discussion, and various governments are beginning to launch broad-based national strategies for tackling obesity (Mayor, 2004). In fact, the World Health Organization approved a Global Strategy for Diet, Physical Activity and Health (World Health Organization, 2004) that calls for multi-sectoral collaboration to address the increasing global prevalence of obesity.

Concluding principles and implications There are several lessons to be learned from other successful public health initiatives, but there have been relatively few scholarly efforts to identify the types of interventions that have external validity and that can be generalized across a number of public health problems. Most of the scholarship has focused on tobacco control and the lessons it may provide for preventing adult and childhood obesity as reviewed in this chapter. Following are six issues that are central in considering a public health approach to preventing obesity. 1 Individual responsibility versus collective action: One of the greatest challenges in our efforts to prevent obesity is to strike the right balance between individual versus structural or environmental efforts to address obesity (Kersh & Morone, 2002; Zernike, 2003). As with many public health problems, a critical issue is the role of regulatory or legal coercion versus the (p.223) protection of free speech and other individual rights, and striking the appropriate balance between commercial interests and the common good (Gostin, 2000). 2 Need to change social norms about food and physical activity: No one could have predicted the magnitude of change in perceptions and public opinion that has occurred with tobacco, but similar changes are possible with respect to food and physical activity. Today, foods are ‘supersized’ to provide the most food or value for the dollar, with little consideration for health on the part of consumers. Although there is nothing wrong in seeking ‘value’, in the future it is possible that health considerations will enter the equation in calculating ‘value’ and the costs of illness will be part of the calculation of the price of a product. Similarly, nearly all smokers who quit, enjoyed smoking greatly, but quit because they were more concerned about their health than they were about the pleasure of smoking. The same

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weighing of pleasure versus health may occur in the future. It would be ideal if social norms could converge so that pleasure was equated with health. 3 Learn from other public health experiences, but do not necessarily duplicate: People need to eat, but do not need to smoke. In addition, it is illegal to sell tobacco products to minors, marketing to minors is prohibited, and nonsmokers’ rights is a powerful social movement that has changed public norms related to smoking. None of these elements exists for preventing obesity. From a macro perspective, and although progress has taken decades, tobacco control is relatively simple compared to the complexities presented by obesity. Accordingly, obesity prevention strategies should be developed with an appreciation for this complexity. 4 The role of the food industry is critical but uncertain: Part of the success of the tobacco control movement was achieved by vilifying tobacco companies. It is unclear whether a similar strategy is warranted, or would be effective, directed against media conglomerates or food companies. This question will be partially answered by the extent to which these companies deal honestly and constructively with the obesity epidemic, including a candid assessment of their role in helping to create it (Revill, 2003). To the extent that commercial interests respond, if not lead, on behalf of the public good, they may obviate the need for government action. To the extent they fail, government action will be demanded (Yach et al., 2003). It appears clear to most that the overall environment in which food products are produced, marketed, and sold, must continue to be improved (Ebbeling et al., 2002). 5 The problem is multi-factorial, and so must be the solutions: Based on their complexity and the experience with many different public health problems (e.g. tobacco control, motor vehicle, and firearm injuries (Bonnie et al., 1999), etc.), it seems clear that comprehensive and multi-factorial approaches are required, which, at a minimum, address both the individual behaviours and the social environment in which these behaviours take place, particularly the marketing, price, availability, and accessibility related to both dietary and physical activity behaviours. It is important to avoid glib and simple solutions to complex and poorly understood problems. 6 Need evidence on best practices and effective interventions: The rise in the prevalence of obesity is well documented, but the causes are less well understood. The relative contributions of dietary factors, the social environment and physical activity, and their interactions, need to be better understood (Jain, 2004). Reports by the American Psychological Association (2004) and the Kaiser Family Foundation (2004) will advance our understanding of the role of the media in childhood obesity, but similar analyses are needed for other aspects of obesity prevention in all age groups. In addition to more studies of the role of fast foods, soft drinks, and dining outside the home, research is urgently needed on parenting, maternal and paternal obesity, the built environment, and how the social environment can be structured to contribute to the (p.224) prevention of obesity. Once the relative effectiveness of various interventions is better known, there needs to be a concerted effort to disseminate and implement approaches that have been found to be effective. The lack of emphasis on the systematic diffusion of effective interventions has plagued multiple public health initiatives. References

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NHANES. (2009) Fourth national environmental exposure report. CDC, National Center for Environmental Health. [Accessed December 10, 2009]. Nestle, M. (2003) Increasing portion sizes in American diets: more calories, more obesity. Journal of American Dietitians Assocication 103(1), 39–40. O’Toole, T., Anderson, S., Miller, C., & Guthrie, J. (2007) Nutrition services and foods and beverages available at school: results from the school health policies and programs study 2006. Journal of School Health 77(8), 500–521. Outley, C.W. & Taddese, A. (2006) A content analysis of health and physical activity messages marketed to African-American children during after-school television programming. Archives of Pediatrics and Adolescent Medicine 160, 432–435. Parmet, W.E. & Daynard, R.A. (2000) The new public health litigation. Annual Review of Public Health 21, 437–454. Powell, L.M., Szczpka, G., & Chaloupka, F.J. (2007) Exposure to food advertising on television among US children. Archives of Pediatrics and Adolescent Medicine 161, 553–560. Quesenberry, C.P., Caan, B., & Jacobson, A. (1998) Obesity, health services use, and health care costs among members of a health maintenance organization. Archives of Internal Medicine 158, 466–472. Revill, J. (2003) Food giants join Britain’s war on flab. The Observer, November 16, 2003. Robert Wood Johnson Foundation. [Accessed December 10, 2009]. Ryan, K.W., Card-Higginson, P.C., McCarty, S.G., Justus, M.B., & Thompson, J.W. (2006) Arkansas fights fat: translating research into policy to combat childhood and adolescent obesity. Health Affairs 25(4), 992–1004. Shults, R.A., Elder, R.W., Sleet, D.A., et al. (2001) Reviews of evidence regarding interventions to reduce alcohol-impaired driving. American Journal of Preventive Medicine 21(4S), 66–88. Schroeder, S.A. (2004) Tobacco control in the wake of the 1998 Master Settlement Agreement. New England Journal of Medicine 350(3), 293–301. Sowden, A.J. & Arblaster, L. (2000) Mass media interventions for preventing smoking in young people (Cochrane Review). Cochrane Database of Systematic Reviews (2), CD001006. Story, M. & French, S. (2004) Food advertising and marketing directed at children and adolescents in the US. International Journal of Behavioral Nutrition and Physical Activity 1(1), 3. Trust for America’s Health. (2007) F as in Fat: how obesity policies are failing in America. [Last accessed December 10, 2009]. United States of America v. Philip Morris USA, Inc., et al. (2006) Civil Action No. 99-2496 (GK).

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U.S. Department of Health and Human Services. (2000). Reducing tobacco use: a report of the surgeon general. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, Georgia. U.S. Department of Agriculture, Food and Nutrition Service. (2005) USDA Awards $9 Million to promote fresh fruit and vegetable consumption in schools. [Accessed December 10, 2009]. Vartanian, L.R., Schwartz, M.B., & Brownell, K.D. (2007) Effects of soft drink consumption on nutrition and health: a systematic review and meta-analysis. American Journal of Public Health 97, 667–675. Vernick, J.S., Mair, J.S., Teret, S.P., & Sapsin, J.W. (2003) Role of litigation in preventing product-related injuries. Epidemiologic Reviews 25, 90–98. Wang, F., Schultz, A.B., Musich, S., McDonald, T., Hirschland, D., & Edington, D.W. (2003) The relationship between National Heart, Lung, and Blood Institute weight guidelines and concurrent medical costs in a manufacturing population. American Journal of Health Promotion 17(13), 183–189. Ward, J.W. & Warren, C. (2007) Silent victories: the history and practice of public health in twentieth century America. Oxford University Press. Warner, K.E., Jacobsen, P.D., & Kaufman, N.J. (2003) Innovative approaches to youth tobacco control: introduction and overview. Tobacco Control 12, i1. Wechsler, H., Devereaux, R.S., Davis, M., & Collins, J. (2000) Using the school environment to promote physical activity and healthy eating. Preventive Medicine 31, S121–S137. Wee, C.C., Phillips, R.S., Legedza, A.T.R., et al. (2005) Health care expenditures associated with overweight and obesity among US adults: importance of age and race. American Journal of Public Health 95, 159–165. World Health Organization (2004). Global strategy on diet, physical activity and health. [Accessed December 10, 2009]. World Health Organization. Frequently asked questions about the WHO global strategy on diet, physical activity and health. [Accessed December 10, 2009]. Wiecha, J.L., Peterson, K.E., Ludwig, D.S., Kim, J., Sobol, A., & Gortmaker, S.L. (2006) When children eat what they watch: impact of television viewing on dietary intake in youth. Archives of Pediatrics and Adolescent Medicine 160, 436–442. Yach, D., Hawkes, C., Epping-Jordan, J.E., & Galbraith, S. (2003) The World Health Organization’s framework convention on tobacco control: implications for global epidemics of food-related deaths and disease. Journal of Public Health Policy 24(3/4), 274–290. Zernike, K. (2003) The nation: food fight; is obesity the responsibility of the body politic? [Accessed December 10, 2009].

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Towards a children’s food and nutrition policy

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Towards a children’s food and nutrition policy Anthony Worsley

DOI:10.1093/acprof:oso/9780199572915.003.0020

Abstract and Keywords This chapter examines several themes which relate to the development of children's food and nutrition policies. Although many of the examples described focus on Australian settings, the themes explored can be applied to settings and sectors in many countries. The chapter briefly reviews children's food and nutrition issues, poses the need for government or community led policies, proposes a food policy knowledge management process, provides some examples of the sorts of information that can be garnered from population monitoring, and ends with an attempt to flesh out some of the elements of a children's food and nutrition policy.

Keywords: health promotion, obesity, prevention, intervention, program, planning, marketing, advertising, law, regulation

Chapter summary This chapter examines several themes, which relate to the development of children’s food and nutrition policies. Although many of the examples described here relate to Australian settings the themes explored are likely to relate to settings and sectors in many countries. The chapter briefly reviews children’s food and nutrition issues, poses the need for government or community led policies, proposes a food policy knowledge management process, provides some examples of the sorts of information that can be garnered from population monitoring, and ends with an attempt to flesh out some of the elements of a children’s food and nutrition policy. A related paper on school-based nutrition promotion is provided in Worsley (2005).

Introduction

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The state of children’s health The majority of children in affluent countries have good health but there appears to be a growing minority whose health and well-being are not optimal. The recent interest in the prevention of obesity among children (Bell & Swinburn, 2005; Lobstein et al., 2004) has focused attention on children’s eating and physical activities. Many children in affluent societies consume more energy dense foods and undertake less physical activity than their parents’ generation (Gregory & Lowe, 2000; Lobstein et al., 2004; Magarey et al., 2001). In part, this appears to be associated with intensive food marketing aimed at school children (Story & French, 2004). Although overweight and obesity are only part of children’s health problems they do tend to attract governments’ attention and resources, often to the detriment of other issues. It should be noted that food and nutrition problems cannot be divorced from other social and health problems. The dietary problems of children and their families vary according to age group, socioeconomic background, and other factors. Briefly, they include: i Increasing prevalence of obesity and risk of associated diseases like diabetes and heart disease. This is associated with social ostracism, depression, and physical illness. These cause heartbreak in families, low quality of life, and major losses for the community in terms of lost contributions from the individuals concerned and health care costs. Lack of physical activity, excessive saturated fats and salt, and energy-rich diets appear to be the key causes (Baur, 2008; Gill et al., 2009; INTERSALT, 1988). ii Micronutrient deficiencies appear to be prevalent among Australian children and adolescents. They include iron and calcium deficiencies, vitamin D and iodine deficiencies among others (Bai, 2009). Such deficiencies can result in major disabilities like poor bone density (p.230) and osteoporosis, poorer intellectual and learning performance, and depression (Bowman & Russell, 2006). Another prevalent deficiency is dietary fibre deficiency – exhibited most clearly in reports of constipation among children and adults. iii ‘Fussy’ eating and bland diets (often linked to food neophobia) may be common in young children, often associated with refusal to consume a wide variety of foods in favour of bland, smooth, high-energy foods (Russell & Worsley, 2008). Parents may not know of suitable foods to feed children, and if they do, they may not have the confidence or strategic skills to withstand their children's initial refusal to consume unfamiliar foods (Worsley & Crawford, 2005). Some dietitians argue that lack of parenting and feeding skills is a likely cause of overweight and obesity (Worsley & Crawford, 2005). Children, however, are not the only people with these nutritional problems – their parents share them and usually in more advanced states! There is a great danger that prevention efforts are solely directed at children while ignoring the fact that they are highly dependent on their parents, families, friends, and schools. Their food practices need to be improved too. What do we do about these problems? Clearly, children’s health should be promoted and help should be given to those children and families who exhibit signs of ill health and poor well-being. The dilemma is over the sorts of actions that should be taken. There is a tension between those who want to take immediate

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action and those who would like to research the problems further using more evidence-based approaches. Similarly, there is a difference of focus between those who see dietary and health issues in terms of proximate biomedical risk factors (and so propose to reduce the risk factors) and those who focus on more distal social determinants of health (hence actions to increase employment and educational opportunities, for example). Furthermore, there is the perennial debate between those who see solutions in terms of individuals’ actions and those who emphasize government responsibilities. There are no simple answers to these types of questions. Instead, progress towards the development of an effective children’s food and nutrition policy might best be made through a process of knowledge management. However, governments and the community have stewardship responsibilities in the area of public policy (Nuffield, 2008). Government’s key role is to ensure that all citizens have the opportunity to lead healthy lives; what Baum (2008) calls ‘flourishing lives’, regardless of their background. Effective policies need to be developed, which rid children born into disadvantaged backgrounds of the social and environmental barriers that impede their healthy development. The laissez faire free market policies pursued in Anglo countries (in particular) during the past 30 years clearly have not produced health for all children and to varying extents have overseen increasing health disadvantages (Pusey, 2003; Wilkinson & Marmot, 2003).

Knowledge management for children’s healthy food policies Food and nutrition involve open systems comprising a complex mix of political, economic, social, psychological, and biological influences. Despite the ever-increasing amounts of information spewed out by scientific endeavours, much of our knowledge is partial and transient so it becomes difficult to base public policies on the evidence available. Fortunately new approaches to knowledge production and management may be helpful. In Fig. 20.1, a five-segment knowledge management schema is illustrated. Readers should be cautioned that although the arrows in the diagram work clockwise, in reality there are complex relationships between these segments; both anti-clockwise and transverse relationships are likely. The segments however, illustrate the sorts (p.231)

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of information that are required for the operation of a set of healthy food policies. They involve the following sorts of information: A Monitoring and surveillance involve systematic observation of population phenomena such as food consumption, beliefs and attitudes towards foods, social norms about eating (e.g. what is ‘proper’ to serve at children’s parties) as well as nutrition status and anthropometric indices. The recent British Achieving Cultural Change report (Strategy Unit, 2008) emphasizes the need to monitor regularly consumer cultures as they relate to health and food phenomena. Unfortunately, this has rarely been done in Australia; the

Fig. 20.1 A schematic showing the ongoing need for Monitoring, Research, Review, Communication, and Sectoral change.

Nutrition and Physical Activity survey (Commonwealth Department of Health and Ageing, 2007) was the first ever and a one-off. It is important to monitor public opinion about policy options, so that policies adopted by government and other stakeholders (such as schools) are likely to be considered feasible and acceptable to most people, especially parents. Two of our own studies illustrate the potential for citizen consultation and participation: i Adults’ views of food policies for school children Despite their central role in their children’s welfare, parents’ views of school food policy options have rarely been examined. Many Australian parents are critical of current children’s school food and nutrition education even though they may hold ambivalent attitudes towards the sales of snacks and food marketing in schools (Worsley, 2007). Three hundred and fifty seven adults were recruited from the electoral rolls in Victoria and asked about their views of school food policy issues (Worsley, 2006). Their responses are (p.232) outlined in Table 20.1. There were few differences in the views of parents and non-parents. Most respondents were strongly in favour of the provision of healthy foods at school and against the marketing of energy dense, low nutrient foods and beverages, and a substantial minority thought government should subsidise the serving of healthy foods at school. Around 90% of the respondents indicated that life skills education should be part of the school curriculum; e.g. learning how to cook and shop, grow fruit and vegetables, and deal with advertising and marketing. Similarly daily physical education programmes and government promotion of nutrition and physical education were endorsed by over 80% of the respondents. Much lower numbers of respondents, however, were willing to pay more income tax to fund such initiatives or to volunteer for canteen duties.

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ii Adults’ views of policies for the prevention of children’s obesity In another survey of Victorians (n = 315, Hardus et al., 2003) respondents were asked what actions could be taken to prevent obesity in children (Table 20.2). Government was expected to take a number of actions by substantial proportions of the same such as the banning of the advertising of high fat foods during children’s television viewing hours or the building of sage cycling and walking tracks. Again, however there was strong support for health promotion and education – e.g. the promotion of healthy eating on television, daily PE programmes at school, healthy eating and physical activity campaigns in the media, and the highlighting of energy content on food labels. These two studies show that there is strong support among the citizenry for policy actions. In particular, government is expected to play a major stewardship role. Public opinion can change over time so regular monitoring is required to gauge the acceptability of policy actions over time. This would also enable the assessment of the effects of various policy programmes on public opinion. Surveillance and Monitoring systems are required to track: ◆ The views, perceived problems, and knowledge of parents – do they realize the problems involved with their children’s diets, how might they help their children; what services do they require? ◆ The views and knowledge, food practices, and preferences of children at various ages – what do they eat, do they have regular meals, what needs and wants do they have? ◆ Health status indices of children (and their parents) year by year; e.g. BMI, WHR, stress levels, food pattern assessments, nutrition status, fitness assessments, biomedical risk factors, attitudes to food, eating, and physical activity. This has commenced in Australia through the implementation of the Australian Early Development Indices. Monitoring of the child population (and their families) should be done in a regular timely manner on random population samples (and perhaps at sentinel sites; e.g. the U.S. Pediatric and Pregnancy Nutrition surveillance system uses height and weight data from children's hospitals to determine prevalence of stunting, among other conditions). B Research is vital for the formation of food policies. Research can be defined as organized data collection. It produces much information at ever-increasing rates (‘this year more research findings will be published than in the whole of human history’). As a glance at nutrition, medical, and food science journals shows, much research is being carried out to explore biological processes (from molecular biology to human physiology and behaviour) related to food and health. There are also developments in health economics and food psychology, which examine processes involved in the purchasing of food products and the costs of nutritionally relevant diseases and the cost benefits associated with prevention interventions (p.233) Table 20.1 Adults’ views of school food policies (data from Worsley (2006)

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1 Healthy food at school

% Agree

All schools should have school food policies which limit the kinds of foods that can be served at school

74

All soft drink and confectionery vending machines should be banned from schools …

72

Food companies should not be allowed to market high energy and high fat products at school …

78

Foods high in fat, salt and sugar should not be served at school canteens (i.e. chocolate, lollies, potato chips)

64

Only healthy foods should be available at school

49

School canteens should not sell hot chips

44

Soft drink vending machines are acceptable in schools

15

2 Meal subsidies Schools should provide supervised, after school care

63

Governments should subsidize healthy school meals

41

Special staff should be paid to prepare food for children at school or in preschool

38

The government should subsidise school meals …

33

Schools should provide breakfast for children …

28

Schools should provide breakfast, lunch and tea …

10

Schools should serve breakfast, lunch and dinner

9

3 Life skills education School canteens should sell fresh fruit

97

All boys and girls should learn how to shop and cook

94

Children should learn how to shop for healthy foods

93

Children should learn to cook while at school …

87

Children should be taught how to deal with advertising and marketing in school lessons …

80

Primary schools should have an active school garden in which fruit and vegetables are …

69

4 Anti marketing at school It is okay if companies like Cadburys and McDonalds sponsor school sports teams

55

Chocolate fundraisers at school are fine

49

Sponsorship of school activities by companies like Cadburys and McDonalds should be banned

30

Chocolate fundraisers should be banned

21

5 Nutrition and pe promotion

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1 Healthy food at school

% Agree

All schools should offer daily PE programmes …

81

Governments need to spend more on promoting nutrition and physical activity in 81 schools … Parents should volunteer for the school canteen

57

I would pay an extra 0.5 % income tax for effective school nutrition and physical 44 education programs Private caterers should not provide food for schools

13

(p.234) Table 20.2 Lay views of polices for the prevention of children’s obesity (Hardus et al., 2003) 1 Government action % Very & extremely important High fat foods should have an additional 5% tax

38

Give 5% tax incentives to manufacturers of healthy food

42

Advertising of high fat foods should be banned during children’s viewing hours

53

The government should build more safe cycling and walking tracks

63

Obesity prevention actions should only be directed to children who are overweight but not yet obese

40

2 Children’s health promotion Healthy eating should be promoted on children’s TV

91

Obesity prevention actions should be directed to all children

82

More healthy food should be served in schools

43

Daily physical education in school should be compulsory

81

3 Other policy actions The government should run regular healthy eating and physical activity campaigns in the mass media

76

Food labels should highlight the calorie/kilojoule content of foods 79 Children should spend no more than one hour a day watching TV or playing computer games

58

The food industry should reduce the portion sizes of take away foods

35

(Dalziel & Segal, 2007). The increased awareness of environmental crises is opening up new research into product life cycle analyses (Williams et al., 2006) and food distribution systems (Larsen et al., 2008) as well as a greater emphasis on factors which affect food security (Burns, 2004; EC-FAO, 2008). In mainstream nutrition, there are signs of a shift away from

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deficiency-oriented single nutrient studies towards the examination of the roles of whole foods and dietary patterns in relation to health outcomes (Jacobs et al., 2009; Slattery et al., 1998) In Australia as in many countries, there are several studies of the aetiology of children’s obesity (e.g. Crawford et al., 2006; O’Dea, 2003; Simmons et al., 2008; Wake et al., 2007; see also Crawford & Jeffrey, 2005) and its prevention (Campbell et al., 2008) as well as the promotion of nutritious foods like fruits and vegetables (Pollard & Miller, 2005; Tapper et al., 2003). There is also renewed interest in the detection of children and families who fail to achieve optimal development (Australian Early Development Indices, 2009). This is associated with the study of various forms of resilience such as personal and family resilience (Ball et al., 2002), community resilience, and the roles of schools and communities in assisting the healthy development of children and adolescents (Blackmore, 2008). C Review and consolidation – the production of knowledge. Research outputs are largely fragmented, scattered, and rarely designed with children’s food policy in mind. They are difficult to summarize. The few instances when research findings are reviewed for food policy formation involve the irregular renewal of various sets of dietary guidelines. Rather than being one-off events, such reviews should be continuing, enabling the knowledge output (as distinct from information inflows) to develop steadily. (p.235) Attempts have been made during the past decade to set up information systems which enable the review of research findings and the distillation of ‘factoids’ which can be used to form ‘knowledge’ (organized systems of validated beliefs) for health policy and promotion purposes. Foremost among these is the Cochrane Collaboration, which is focused on biomedical studies. Its rather rigid evidence hierarchy has been adopted by a number of health research organizations such as the Australian NHMRC as part of the evidence-based medicine movement. This may be appropriate for biomedicine but it is not flexible enough for information derived from open systems in which there are large numbers of input and outcome variables measured in many ways. The Cochrane Public Health group (2007), and the Sax Institute (Sydney, NSW Health) have developed useful approaches which provide health policy makers and health promoters with consolidated sets of information (knowledge) for decision-making. This need for review, reflection, and consolidation of knowledge is particularly acute in nutrition for both professionals and the general public. Many of them are either totally ignorant of nutritional facts and approaches, or they are confused by them (or both). The production and delivery of healthy food to children depends in part on government decision makers and professionals in several sectors such as agriculture, manufacturing, marketing, health, and education actually knowing about the health properties of foods and how to maximize these properties. Similarly, parents need to be aware of the health properties of foods (and what affects them) if they and their children are to lead healthy lives. A major review of nutrition services for pre-schoolers conducted by Montague (2002) showed that professional child care and education professionals, organizations, and parents were confused by conflicting nutrition information. All of them wanted one source of authoritative food and health advice. Apart from the general services of some professional bodies such as the Dietitians’ Association of Australia, this recommendation has not been acted upon. To do so would require the services of specialist nutrition reviewers and communicators.

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Review of research information is likely to influence the research agenda. For example, once the healthy eating objectives of a Children’s Food and Nutrition Policy are defined it is likely that there will be a need for research to identify the best ways to achieve those objectives. Similarly, advocacy groups will require information about nutrition issues and population practices. D Communication and sectoral change When knowledge frameworks are developed and populated with facts, it becomes possible for communication to occur. This can be put to many uses in many forms. For example, food producers, retailers, media channels, government health policy makers, pre-schools, schools, and health services need to provide settings in which healthy food consumption is made more likely. There are major opportunities to engage workers in these sectors through extension services, which could be based on Web2. Other forms of communication involve community action research and demonstration projects (community interventions).

Towards a children’s food and nutrition policy It is clear from the intervention research literature (Worsley & Crawford, 2005) and from stakeholder consultations (Montague, 2002) that much can be done to improve children’s eating and nutrition status. Many interventions worldwide have been successful in improving the quality of foods consumed by young children and their families (e.g. Foley et al., 1997, Foley & Pollard, 1998, Tapper et al., 2003, Worsley & Crawford, 2005). Unfortunately most interventions are just that, externally initiated, short term, with little or no follow-up and piecemeal. Most have been imposed on health and education systems rather than grown from within them. (p.236) Many thousands of teachers, nurses, and other professionals are paid to care, educate, and look after the health of children. A Children’s Food and Nutrition policy would enable these professionals to empower children and their families to eat more healthily, as that would be a key purpose of their employment. We do not need more interventions imposed from the outside – instead we need to reorient the goals of the health and education systems so that they promote healthy eating (and associated physical activity) goals. So what would a food and nutrition policy for children and adolescents look like? It would have a set of concrete feasible long-term objectives, say over the next 5 to 10 years. These would tackle the food and health problems outlined earlier. Possible objectives would include: ◆ the halting of the current children's obesity epidemic, measured by defined reductions in obesity incidence and prevalence rates; ◆ increases in the consumption of fruit, vegetables, and cereals, reductions in the incidence and prevalence of micronutrient deficiencies by set amounts; ◆ development of wider food preferences among children – again defined in measureable ways; ◆ increases in the numbers of children consuming pleasant nutritious meals each day (i.e. reductions in the numbers who do not have a nourishing breakfast, lunch, or dinner);

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◆ reductions in food borne illness including food-related anaphylaxis; and, ◆ similar changes in children’s families, especially among their parents.

Strategies These will be required to achieve the policy’s objectives, including: Advocacy. A Children’s Food and Nutrition Policy is likely to conflict with the interests of other policies and groups (e.g. literacy and numeracy policies, business interests, etc). Therefore, advocates are required to promote nutrition policy goals over or alongside conflicting alternative interests. Advocates are needed to resist such (well-meaning) pressures. More advocacy groups like the Obesity Prevention Coalition and the Parents’ Jury, which pressure government and industry to reform their operations, are required. Creation of new low energy high nutrient foods, particularly children’s snacks Some food manufacturers make and market energy dense, low nutrient food products to children. These are one factor in the current obesity epidemic. Industry needs positive encouragement to produce and market healthy food products, which are convenient and tasty for children. Although the banning of some products may be tempting, it is important that sophisticated strategies are implemented that use market processes such as competition to deliver healthier products. The Heart Foundation’s Tick programme has already done much to remove salt and saturated fats from the food supply (forthcoming report) but more can be done. Programmes like the UK 5 star energy efficient refrigerator system allowed manufacturers to compete to produce the most efficient refrigerators without too much hurt to themselves or consumers (Strategy Unit, 2008). Partnerships between interested organizations and individuals are necessary. These may include government (e.g. departments of primary industries and health and education), nongovernment organizations like the Heart Foundation and the Cancer Council, the professions, industry organizations, researchers such as the Australian Research Alliance for Children and Youth, and community groups. Partnerships between government and other agencies are required to provide people to implement the policy. Government can provide policy instruments such as (p.237) Table 20.3 Some areas of activity for a children’s food and nutrition policy Area Possible activities Mothers and breast feeding

Education of fathers, family members transport and food service owners and employers, Maternity hospitals and birthing centres join the Baby Friendly Hospital initiative Increase pro-breastfeeding norms

Parents from low SES backgrounds

Adopt FoodCents scheme - targets the motivations of low SES groups; incorporate in school curricula

New parents and families

Provide help and advice - courses and books, telephone advice lines, internet programs and chat rooms, parents' associations, community health centre session; anticipatory parenting (Campbell et al., 2009)

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Area

Possible activities

Pre-Schools and long day care centres

Adoption of Start Right Eat Right and similar training programs for carers.

Primary schools

Develop experiential and cognitive schema of foods, healthy food preferences, food preparation and buying skills.

Secondary schools

Acquisition of life skills including food and health maintenance skills for all secondary students; ideal setting for the promotion of healthy eating.

School Food supply

School food policies to promote healthy, enjoyable eating through business and nutrition training of staff, awards systems, and supply of healthier products, e.g. NSW fresh taste program.

Point of sale programs

Provision of supermarket tours, POS nutrition communication; loyalty programs to promote children’s healthy eating; checkouts to provide feedback about healthiness of purchases.

Reform of professional training (of doctors, nurses, community workers, health promotion workers, etc)

Tertiary courses to include children's healthy eating principles and skills

Community development Focus on access to high quality food and food preparation Demonstrations skills especially for refugee and new migrant groups; positive experiences of community food production; community gardens legislation and regulations to regulate advertising and to provide industry regulations through which healthy foods can be produced and sold. Examples of policy actions in various settings are given in Table 20.3. They are discussed in more detail in Worsley (2008).

Conclusions This brief survey of children’s food and nutrition policy issues shows that although many research and policy activities are being undertaken, there is a need for a more systematic knowledge management process, which will integrate monitoring, research, review, and communication activities into a policy that will reach into the various sectors and settings that affect children’s food consumption and nutrition status. References Bibliography references: Australian Early Development Indices (2009) , (accessed 5 September 2009). Australian Research Alliance for Children and Youth (accessed 5 September 2009). Bai, L. (2009) Nutritional status of adolescents in Australia and New Zealand: an overview. Submitted to Nutrition and Dietetics.

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Ball, K., Brown, W., & Crawford, D. (2002) Who does not gain weight? Prevalence and predictors of weight maintenance in young women. International Journal of Obesity 26, 1570–1578. Baum, F. (2008) Social Inclusion, Don Dunstan Foundation, Adelaide: University of South Australia, April 21. (accessed 5 September 2009). Baur, L. (2008) Tackling obesity in children and adolescents. BMJ 337, 888. Bell, A.C. & Swinburn, B.A. (2005) School canteens: using ripples to create a wave of healthy eating. Medical Journal of Australia 183, 5–6. Blackmore, J. (2008) Leading educational re-design to sustain socially just schools under conditions of instability. Journal of Educational Leadership, Policy and Practice 23(2), 18–22, Unitec Institute of Technology, New Zealand. Bowman, B.A. & Russell, R.M. (Ed.) (2006) Present knowledge in nutrition: Volume 2, 9th edition. International Life Sciences Institute, Washington DC, pp. 373–528. Burns, C. (2004) A review of the literature describing the link between poverty, food insecurity and obesity with specific reference to Australia, Victorian Health Promotion Foundation, Melbourne. (accessed 5 September 2009). Campbell, K., Hesketh, K., Crawford, D., Salmon, J., Ball, K., & McCallum, Z. (2008) The Infant Feeding Activity and Nutrition Trial (INFANT) an early intervention to prevent childhood obesity: cluster-randomised controlled trial. BMC Public Health 8(103), 1–9. Cochrane Public Health Group (2007) (accessed 5 September 2009). Commonwealth Department of Health and Ageing (2007, 2008) 2007 Australian National Children’s Nutrition and Physical Activity Survey- Main Findings. Canberra, Commonwealth Department of Health and Ageing. Crawford, D. & Jeffery, R. (Ed.) (2005) Obesity prevention and public health, Oxford University Press, New York. Crawford, D.A., Timperio, A., Telford, A., & Salmon, J. (2006) Parental concerns about childhood obesity and the strategies employed to prevent unhealthy weight gain in children. Public Health Nutrition 9, 889–895. Dalziel, K. & Segal, L. (2007) Time to give nutrition interventions a higher profile: cost-utility analysis of 10 nutrition interventions. Health Promotion International 22(4), 271–283. EC–FAO Food Security Program. (2008) An introduction to the basic concepts of food security. (accessed 5 September 2009). Foley, M.R. & Pollard, C.M. (1998) FOODcents – implementing and evaluating a nutrition education project focusing on value for money. Australia and New Zealand Journal of Public Health 22, 494–501.

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Foley, M.R., Pollard, C.M., & McGuiness, D.J. (1997) FOODcents – achieving a balanced diet on a limited budget. Australian Journal of Nutrition and Dietetics 54, 167–172. Gill, T., Baur, L., Bauman, A., et al. (2009) Childhood obesity in Australia remains a widespread health concern that warrants population-wide prevention programs. Medical Journal of Australia 190, 146–148. Gregory, L. & Lowe, S. (2000). National diet and nutrition survey: young people aged 4–18 years, HM Stationery Office, London. Hardus, P.M., van Vuuren, C.L., Crawford, D., & Worsley, A. (2003) Public perceptions of the causes of obesity among primary school children and views regarding its prevention. International Journal of Obesity 27, 1465–1471. INTERSALT (1988) Intersalt: an international study of electrolyte excretion and blood pressure. Results for 24 hour urinary sodium and potassium excretion. Intersalt Cooperative Research Group. BMJ 297, 319–328. Jacobs, D.R., Gross, M.D., & Tapsell, L.C. (2009) Food synergy: an operational concept for understanding nutrition. American Journal of Clinical Nutrition 89, 1S–6S. Larsen, K., Ryan, C., & Abraham, A. (2008) Sustainable and secure food systems for Victoria: What do we know? What do we need to know? Victorian Eco-Innovation Lab, University of Melbourne. Lobstein, T., Baur, L., & Uaur, T. (2004) Obesity in children and young people: a crisis in public health. Obesity Reviews 5 (Suppl. 1), 4–85. Magarey A.M., Daniels, L.A., & Boulton, T.J.C. (2001) Prevalence of overweight and obesity in Australian children and adolescents: reassessment of 1985 and 1995 data against new standard international definitions. Medical Journal of Australia 174, 561–564. Montague, M. (2002) Public health nutrition policy in organised settings for children aged 0–12: an overview of policy, knowledge and interventions. A report to the Eat Well Victoria Partnership (accessed 5 September 2009). Nuffield Council on Bio-ethics. (2008) Public health – ethical issues. (accessed 5 September 2009). O’Dea, J.A. (2003) National children’s nutrition and physical activity study. University of Sydney. Pediatric and Pregnancy Nutrition Surveillance System. (accessed 5 September 2009). Pollard, C.M. & Miller, M.M. (2005) Working with industry to promote fruit and vegetables: a case study of the Western Australian fruit and vegetable campaign – a description of approach to inter-sectoral action. Australia and New Zealand Journal of Public Health 29, 176–182.

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Pusey, M. (2003) The experience of Middle Australia: the dark side of economic reform. Cambridge University Press, Melbourne. Russell, G. & Worsley, A. (2008) A population-based study of pre-schoolers’ food neophobia and its associations with food preferences. Journal of Nutrition Education and Behavior 40(1), 11–9. Simmons, A., Sanigorski, A.M., Cuttler, R., et al. (2008) Nutrition and physical activity in children and adolescents. Barwon – South Western Region. Sentinel Site Series. Report 6: Lessons learned from Colac’s Be Active Eat Well project (2002–6). Department of Human Services (Victoria), Melbourne. Slattery, M.L., Boucher, K.M., Caan, B.J., Potter, J.D., & Ma, K.N. (1998) Eating patterns and risk of colon cancer. American Journal of Epidemiology. 148(1), 4–16. Story, M. & French, S. (2004) Food advertising and marketing directed at children and adolescents in the US. International Journal of Behavioral Nutrition and Physical Activity 1, 3. Strategy Unit (2008) Achieving culture change: a policy framework. The Cabinet Office, London. (accessed 5 September 2009). Tapper, K., Horne, P.J., & Lowe, C.F. (2003) Food dudes to the rescue. The Psychologist 16, 18– 21. Wake, M., Nicholson, J.M., Hardy, P., & Smith, K. (2007) Preschooler obesity and parenting styles of mothers and fathers: national population study. Pediatrics 120(6), e1520–e1527. Wilkinson, R. & Marmot, M. (2003) Social determinants of health: the solid facts. World Health Organization Regional Office for Europe, Copenhagen. Williams, A.G., Audsley, E., & Sandars, D.L. (2006) Final report to Defra on project ISO205: determining the environmental burdens and resource use in the production of agricultural and horticultural commodities. Defra, London. Worsley, A. (2005) Children’s healthful eating: from research to practice. Food and Nutrition Bulletin 26, (2) S135–S143. Worsley, A. (2006) Lay people’s views of school food policy options: associations with confidence, personal values and demographics. Health Education Research 21(6), 848–861. Worsley, A. (2007) Lay people’s views of school children’s food services: demographic associations. British Food Journal 109(6), 429–442. Worsley, A. (2008) Nutrition promotion: theories and methods, systems and settings. Allen and Unwin, Sydney; CABI International, New York; Oxford University Press, London. Worsley, A. & Crawford, D. (2005) Review of children’s healthy eating interventions. Department of Human Services, Melbourne.

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Prevention and management of obesity in children and adolescents—the Singapore experience

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Prevention and management of obesity in children and adolescents—the Singapore experience Ting Fei Ho

DOI:10.1093/acprof:oso/9780199572915.003.0021

Abstract and Keywords In this chapter, an overview of the prevalence and health problems of childhood obesity in Singapore provides a backdrop to the discussion on the measures of prevention and intervention of childhood obesity in Singapore and the success and failures of these measures. While there is a lack of major publications on the prevention and management of childhood obesity in Singapore, the various reports and limited publications give us a glimpse into the strategies used, the effectiveness, flaws, and the ongoing programs to combat childhood obesity. In addition, the chapter provides new research data and clinical experience in the areas of childhood obesity and related issues such as eating disorders.

Keywords: research data, Singapore, overweight, obesity, children, diagnosis, measurement, interpretation, Singapore, Asia

Chapter summary In this chapter, an overview of the prevalence and health problems of childhood obesity in Singapore provides a background to the discussion on the measures of prevention and intervention of childhood obesity in Singapore and the success and failures of these measures. Although there is a lack of major publications on the prevention and management of childhood obesity in Singapore, the various reports and limited publications give us a glimpse into the strategies used, the effectiveness, flaws and the ongoing programmes to combat childhood obesity. In addition, the chapter provides new research data and clinical experience in the areas of childhood obesity and related issues, like eating disorders.

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Introduction Economic progress, improved environmental conditions, and health care have led to a shift in the health patterns of Singapore’s population over the last 50 years or so. Malnutrition and infectious diseases were significant health problems in Singapore in the 1950s and 1960s whereas obesity in children was rare (Loke, 2008). Analysis of various anthropometric studies from 1957 to 2002 revealed that weights and body mass index of children 6 to 18 years were increasing over this period of time (Loke, 2008). In a span of 30 years, prevalence of obesity in 7-year-old children increased from 1.4% in 1976 to 12.7% in 2006, whereas that of 12-year-old children increased seven-fold from 2.2% in 1976 to 15.9% in 2006 (Loke, 2008). The overall prevalence of obesity for children and adolescents (7 to 18 years) rose from 2.8% in 1994 to 3.6% in 2007 (Osman, 2009). Although the magnitude of the prevalence of childhood obesity in Singapore is not as alarming as that in the West, the occurrence of obesity-related morbidities in the young is a cause for concern (Fu et al., 2009; Ho, 2009; Lee, 2009) because of the possible relationships between obesity and cancer, cardiovascular disease, and diabetes mellitus. These diseases are among the top ten disease conditions and account for more than 60% of all deaths in Singapore (MOH, 2009). An additional concern is that the relationship between BMI and body fat percentage in Singaporeans and in many Asian populations is different from that observed in Caucasians. At any given BMI, the body fat percentage of Singaporeans tends to be lower than that of Caucasians (Deurenberg-Yap et al., 2000). The risk of cardiovascular disease and diabetes mellitus also occurs at lower BMI points for Singaporeans than for Caucasians (Deurenberg-Yap et al., 2001).

(p.241) Family structure and lifestyle In Singapore it is a common trend to see families with both parents working full-time and often spending long hours at work. Singapore families are generally small with only one to two children per family. It is not uncommon to find adults like grandparents indulging the children and giving in to what the children ask for. With almost 75% to 80% of the population living in high-rise apartments where food stalls and fast-food shops are very close by and foods available at very affordable prices, the fastest and easiest way to satisfy one’s hunger is to buy food from these sources. Spending time and effort to prepare a nutritious meal is a less preferred option compared to the convenience of eating out.

Dietary patterns It is well accepted that, to meet good nutritional standards and to achieve desired BMI status (for the overweight or obese), vegetables and fruits are important in our daily diet. Many are familiar with the requirement for five servings of vegetables and fruits per day. Consumption of vegetables or fruits is however appallingly low in Singapore children and adolescents. In a recent Students’ Health Survey 2006 of secondary school students conducted by the Health Promotion Board (HPB), Singapore, it was noted that there was a big gap between those who knew about taking three servings of vegetables and two servings of fruits daily (70%) and those who actually practised this advice (24%) (HPB, 2006) (Fig.21.1). This was true for both the

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males and females and for the different age groups from the lower to the upper secondary school students. In the same report, it was noted that almost 30% of the students were consuming sweetened drinks more than once a day (Fig.21.1). About 52% of the students reported taking deep fried food more than twice a week (Fig.21.1). (p.242) The long school hours can further affect meal patterns. Singapore schools generally run one session per day with classes starting at about 7.30 am each day and ending around 1 pm. However, many students may continue to stay in school for after-school activities and are home only by 3–4 pm or even later. Such school hours result in many students leaving their homes as early as 6 to 6.30 am without breakfast. Thus late-morning snacks and lunches are commonly taken in school. Dinner may be Fig. 21.1 Pattern of food consumption and the only meal taken at home each day. Such physical activity in Singapore school children (12 to 16 years of age). Data adapted from a meal pattern can lead to dietary HPB (2006). indiscretions unless students are wellinformed and disciplined about their food choices. This also highlights the important roles of health education and regulation of canteen vendors, as described in the following section under ‘National health promotion programmes’.

Physical activity It is a common phenomenon that Singapore school children and adolescents have a low level of exercise and low participation in sports. This is partly due to the heavy commitment to academic studies in an environment that is highly competitive. School hours are often long, stretching for about 7 to 8 hours daily for five days a week. After school hours and weekends are largely taken up by school work and tuition classes, which also include classes for extracurricular activities like music, art, and other enrichment courses. Furthermore, time spent watching television and working or playing at the computer can take up many of the waking hours of school children. Thus, daily sedentary activities for most children and adolescents are overwhelming. Physical education classes in schools are not conducted daily. In some schools it is once a week and in others it may be two or three times a week of about 30 minutes each session. For teachers who do not realize or value the benefits of inculcating good lifestyle habits of regular exercise in students, physical education classes may be sacrificed to allow extra time for academic sessions or activities like remedial lessons (conducted for students who require extra tutoring in certain academic subjects).

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In the 2006 survey of secondary school students, only 19% of all students were engaged in moderate or vigorous physical activity for 30 minutes per day for 5 days or more a week (HPB, 2006) (Fig.21.1). Eight per cent of the students surveyed were found to be physically inactive. In the author’s experience, about 72% of the obese children seen at her practice self-report that they participate in sports for less than three times a week (Ho, 2007). The tropical weather and the transport system in Singapore are additional factors that may explain why students have low physical activity and low participation in sports. In the 2006 survey, 36% of the students commented that it is often too hot to exercise (HPB, 2006). The heavy traffic conditions on most roads can make cycling or walking to school a hazard in many parts of the country even when students live close to their schools.

National health promotion programmes Government reviews of health promotion and disease prevention were initiated in the early 1990s. In 1992 the National Healthy Lifestyle Program (NHLP) was launched. This programme focused on various health issues, which included physical activity and healthy eating (NBR, 2008). In 2001, the Health Promotion Board (HPB) was formed and an NHLP Department was created to coordinate and implement various healthy lifestyle programmes that targeted different population subgroups (NBR, 2008). The strategic framework of HPB uses an approach that reaches out to those who are healthy (e.g. people who are not overweight/obese), those who are at (p.243) risk (e.g. the overweight/obese individuals), and those who are unhealthy (e.g. those who are overweight/obese, have diabetes mellitus, stroke, hypertension) (NBR, 2008). Intervention programmes for childhood obesity The Singapore government recognizes that obesity is a complex problem that requires prevention and intervention policies and programmes to be customized for the population at various settings – in healthcare institutions, schools, communities, and workplaces. Besides various school and community programmes (Table 21.1), HPB has collaborations with several public and private organizations to implement policies and educational programmes to raise awareness about health issues (NBR, 2008). In this chapter the focus is on policies and programmes for children and adolescents. The ‘Trim and Fit’ programme The Trim and Fit (TAF) programme was initiated in 1992 by the Ministry of Education for implementation in Singapore schools, covering a range of school age children from 7 to 18 years of age (Educational levels: primary 1 to junior colleges) (NBR, 2008). The primary aim of this programme was to reduce the prevalence of obesity in school children and adolescents and to raise the level of physical fitness of these obese students using a multidisciplinary approach (Cheong et al., 2002; NBR, 2008). The key objectives of this programme were to promote healthy nutrition and regular physical activity in students through nutrition education and physical education classes in the school curriculum. Resources like sports facilities and equipment, outdoor fitness stations, etc. were provided or improved to cater to this programme. Other peripheral support for this programme was implemented in schools. For example, measures were taken to control the types of food and drinks sold in school canteens and water coolers

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were installed in all schools to encourage students to drink plain water instead of bottled or canned drinks (Cheong et al., 2002). The HPB provided resources to help teachers implement the TAF programme more effectively. Under the TAF programme, overweight and obese students were given special attention. They were selected to participate in special physical exercise programmes and healthy nutrition was further emphasized. Overweight or obese students participated in about one and a half hours of physical activity, like sports or games, each week in addition to their regular weekly physical education classes, which could range from one to two sessions of about 30 to 45 minutes each Table 21.1 Examples of government-initiated programmes for prevention and intervention of obesity in Singapore Programme

Year

Target Population

Trim and fit programme

1992–2006

School children

Holistic health framework

2007–

School children

Model school tuck-shop programme

2003–

School children

Healthier canteen certification programme

2006–

Employees at various workplace

Healthier hawker programme

2006–

General population

Healthier dining programme

2003–

General population

Community programmes to promote physical activity

various dates

General population

The above information is extracted from ‘Obesity Prevention and Control Efforts in Singapore’ (NBR, 2008). (p.244) (Lee, 2003). This was meant to make losing weight through increased physical activity an enjoyable process. These additional physical activity sessions were slotted into the school day either at recess or at designated time before or after school. Obese students who required further assessment and management were referred to the School Health Services, Ministry of Health, for further follow-up, medical screening, and nutrition counseling (Cheong et al., 2002; Lee, 2003). The TAF programme ran for 14 years and achieved some desirable results. Although there are not many published reports on detailed scientific evaluation of this programme, scattered reports from the Ministries of Health and Education, the media, and some independent publications throw some light on the achievements of the TAF programme. There was overall success in decreasing the prevalence of obesity in school children and adolescents and increasing physical fitness levels of students in Singapore (NBR, 2008). The overall prevalence of overweight students decreased from 11.7% in 1993 to 9.5% in 2006 (NBR, 2008). The percentage of students who passed the national physical fitness test had increased from 58% in 1992 to 82% in 2002 (Lee, 2003). Despite the success of the TAF programme in Singapore, it came to a close in 2006 after 14 years of implementation and following a review of the programme in 2005. However, the basic framework of this programme helped to evolve into a new programme called the Holistic Health

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Framework (HHF), which was launched in 2007. The HHF aims to look beyond the narrow concept of obesity prevention and promotion of fitness by embracing a broader view of students’ general health, well–being, and healthy lifestyle (NBR, 2008). It is yet to be seen how this programme will benefit the general population of school children and adolescents and whether this will translate into a lifelong pursuit and adherence to healthy lifestyles, good physical health, and mental well-being even as these school students enter adulthood. TAF programme – its flaws and failures

Stigmatization The real reasons for the closure of the TAF programme are not known and the details of the review of the programme in 2005 have not been published. One can only draw some speculative conclusions from the few government statements, media reports, and some personal contacts of the author with parents of obese children who were members of the TAF programme. In addition, data from the author’s study of eating disorders in Singapore females may help to shed some light on the flaws and failures of the TAF programme. One main criticism of the TAF programme came primarily from parents who complained that the programme singled out overweight and obese children and made them easy targets for teasing by their peers in school (The Associated Press, 2007; PRI’s The World, 2007). Reports in other foreign press also highlighted this problem of stigmatization. It was felt that the insult and social ostracism might have contributed to the ‘success’ of the TAF programme in achieving the goals of losing weight but at a heavy price where some members of the TAF programme suffered from psychological scarring (Zeckhausen, 2008). Similarly, the negative impact of being in the TAF programme was felt through the use of food ration coupons for overweight and obese students, the embarrassment of being segregated and the frustration of failing to lose weight as expected (Agence France Presse, 2005). The comments by a TAF programme participant clearly pointed to the shame that served as a negative motivation to lose weight: ‘… I want to lose weight so that I can leave the club, then people won’t call me names anymore’. The stigma of being called ‘fat’ could stay with these students for a long time, ‘lower their selfconfidence and impede their future goals’ said Carol Balhetchet, a child psychologist and the Director of Youth Development at the Singapore Children’s Society (Agence France Presse, 2005). (p.245) Eating disorders About the same time that the TAF programme was under review, a report of a retrospective study of 126 patients at the Eating Disorder Clinic, Institute of Mental Health, Singapore, was published in 2005 (Lee et al., 2005). Between the years 1994 to 2002, the number of newly diagnosed cases of Eating Disorders (ED) increased four-fold. Among the 126 patients, 11% were previously members of the TAF programme. In the same year, several researchers that included the author (principal investigator) and a team of psychiatrists reported their study of 4400 females (ages ranging from 12 to 24 years) randomly selected from eight Singapore secondary schools, a polytechnic, and a university. These female subjects had no history of any ED or other significant medical problems. The results revealed that about 7% of these 4400 females were at increased risk of developing ED. Of those at risk, about one-third reported that

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they had been in the TAF programme and about 60% of these TAF participants reported that they had been teased about their weight (Ho et al., 2006). A media report gave a description of the above two studies and concurrently published a case report of a young teenage girl who developed ED and lost 12 kg after just 5 months in the TAF programme. The event that was likely to contribute to her ED was the fact that she was the only student in her class picked for the TAF programme. She was called names and had the words ‘TAF FAT’ doodled on her exercise book. The development of ED led her to seek psychiatric help and she had since regained some weight (Davie, 2005). Whereas this case report was one anecdotal example of EDs arising from participation in the TAF programme, there were other such cases that were not reported but were being seen at public or private clinics for ED of varying severity. The author herself had seen and managed such cases in her weight management clinic for children and adolescents. The detailed history of each patient might be different but the underlying predisposing factors were similar. Children and adolescents were at increased risk to develop an ED when they were placed in situations that exposed them to malicious name-calling, being associated with attributes like fat, lazy, slow, stupid – all likely to promote a negative body image. Just as a TAF participant who developed ED rightly described it, ‘It was nightmarish … I was desperate to lose weight and fast …’ What faster way to lose weight and get out of TAF as soon as possible than by not eating or vomiting out the food that one ate? The association between the TAF programme and ED was possibly through segregation of the overweight or obese students and making them easy targets of abuse and shame. Implementation Although schools are one of the best places to implement national policies and strategies for prevention and intervention of obesity in school children, it can also pose some challenges. Unless a programme is implemented under tight control with appropriate leadership, clear objectives and instructions, and adequate manpower and resources, then irregularities and shortfalls can arise. Maintaining consistency in the on-going progress of the programme can be logistically challenging. Inadequate training and supervision of those involved in the practical execution of the programme can lead to misinterpretation of the objectives and errors. Schools may resort to vastly different ways of conducting the programme. It was argued that a carrot-and-stick approach to implementation of the TAF programme had resulted in its success (Agence France Presse, 2005). However, while striving to avoid the ‘stick’, schools can become too harsh on obese students who are already singled out for ridicule, thus adding to the negative repercussions. Errors can arise from the detection of overweight or obese students if teachers are not clear about the definitions of overweight and obesity or if the measuring instruments are invalid or poorly calibrated. Supervision and quality control are necessary to ensure that there is consistent (p.246) adherence to the protocol or programme. Regular evaluation of outcomes and feedback is essential to detect any deviations, irregularities, or flaws so that the programme can be modified or fine-tuned as it progresses. One major source of criticism that no doubt

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contributed to the review of the TAF programme came from parents. This is a useful source of feedback and should not be ignored. Although there were no objective reports to support whether the flaws or shortfalls mentioned earlier did exist, there were criticisms of the TAF programme (Agence France Presse, 2005; The Associated Press, 2007) and there were repercussions like ED in students who were previously members of the TAF programme (Ho et al., 2006; Lee et al., 2005). Model School Tuckshop programme In every Singapore school there are tuck-shops where vendors sell food and drinks to the students. Each of these vendors has a little store and the stores are grouped together under what we call tuck-shops. Students are free to choose and buy the foods and drinks during recess or anytime outside school hours. In 2003, the Model School Tuck-shop Programme (MSTP) was introduced to ensure that healthier food choices are available to the school children (NBR, 2008). Under this programme, schools were provided with guidelines whereby students were encouraged to increase consumption of vegetables and fruits while consumption of fat, salt, and sugar was limited. For instance, water coolers were installed in schools. Sale of deep fried food and preserved meats was limited to only once a week. In addition, culinary training workshops were conducted to educate vendors on how to prepare more healthy food for the students. MSTP is a voluntary programme. Schools are regularly assessed by personnel from HPB. The schools that meet the requirements of the guidelines are awarded MSTP status. So far, about 74% of Singapore schools have achieved MSTP status (NBR, 2008). Other related programmes The HPB has initiated other community or social programmes that can have an indirect impact on influencing the lifestyle of children and adolescents. These programmes are implemented in the workplace, community, or schools either by the HPB or in collaboration with other partners. Some of these include the Healthier Hawker Programme, Healthier Dining Programme, and the Healthier Canteen Programme, all of which encourage healthier dietary practices in adults (NBR, 2008). Such practices can influence the attitudes of adults towards healthy diet and, in turn, can influence their family members. Singapore school curricula include Health Education and Home Economics lessons where school students learn the importance of healthy nutrition and regular exercise (NBR, 2008). Such educational sessions are developed under the collaboration between HPB and the Ministry of Education. The curricula reach out to a wide range of age groups from pre-school children to students in tertiary institutions. Overall, the Singapore government has initiated various programmes for promotion of health and disease prevention in the population. The TAF programme, in particular, is to control and manage obesity in school children and adolescents. Others are programmes that are targeted at different levels of the population at the work place and in the community. Although the TAF programme has achieved certain success in reducing the prevalence of obesity in children and

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adolescents, it has suffered some setbacks and has been replaced by a more holistic programme in 2007.

The Singapore military experience When Singapore started compulsory military service for all 18-year-old males in 1967, the recruits were more often underweight rather than overweight (Walsh, 2004). However that scenario (p.247) has changed in the past two decades or so. From a paper published in 1994, it was noted that the prevalence of obesity in 18-year-old male recruits entering National Service had risen from 5.9% in 1984 to 10.4% in 1989 (Lee et al., 1994). The then Prime Minister of Singapore had warned that ‘If we are not rugged, fit and healthy as a society, we will not be able to withstand the pressure of competition, endure the rigors of military training and survive the heat of battle’ (Walsh, 2004). Obese recruits were previously considered at higher risk of training injuries and heat injuries and were not required to undergo combat training. However, in order that obesity did not constitute an exclusion criterion for combat training, an extended 5-month basic military training (BMT) programme was initiated in 1991 for obese recruits in order for them to lose weight (Lee et al., 1994). Under this 5-month BMT, obese recruits were required to stay in camp for the entire 20 weeks. The training programme included an initial phase of conditioning (8 weeks) and a second phase (12 weeks) of combat skills training. Intensity of physical activity increased gradually with almost 57% of the training considered intense during the 5-month period. There were no dietary restrictions and the recruits ate food according to the standardized menu at the Singapore Armed Forces. The usual diet for each person consisted of 3066 kcal a day with 110 gm of protein, 85 gm of fat, and 470 gm of carbohydrate (MINDEF, 1992). In addition, the recruits attended lectures on health and nutrition and received guidelines on the quantity and quality of food to be consumed (Lee et al., 1994). A cohort of 175 moderately to severely obese recruits who completed the BMT regime was studied (Lee et al., 1994). Using percentage body fat (%BF) as an indication of the degree of obesity (%BF 24 to 〈30%, ≥30 to 〈 35%, ≥35%), the higher the %BF the greater the mean weight lost over the 20 weeks. The weight loss was primarily due to loss of fat mass (mean loss of 40% over 20 weeks) with minimal loss of lean mass. By the end of the 20 weeks, one-third of the subjects were defined as non-obese. The remaining had lost sufficient weight to be considered mildly obese (%BF 〈25%). This study (Lee et al., 1994) revealed that intense physical activity alone over a 5-month duration could achieve adequate weight loss for young men who were moderately to severely obese. Such success was achievable because the subjects were under strict supervision where they kept to the regime consistently for the 20 weeks of training. Although the success of weight reduction is obvious, the results are relatively short-term, over the period of intervention and during the two and half years of military service. What is lacking is more long-term evidence of the weight and fitness status of these subjects. It is not known whether the weight loss and fitness are sustainable and whether there is any beneficial and

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sustainable change in lifestyle many years after these soldiers leave military service and return to their civilian lives. Such long-term outcomes are more important but there are as yet no known studies or publications to address these interesting and pertinent questions.

Conclusions The Singapore experience in prevention and intervention of obesity has not only some features common to those practised globally but also unique features that are highlighted earlier. Noteworthy are the nation-wide programmes implemented by the government to control the problem of overweight and obesity in the population. These are targeted at various levels in the schools and community for children and adults. In particular, the TAF programme and the school tuck-shop programme are targeted at school students. These have achieved significant success in reducing the prevalence of obesity. However, there are also criticisms, flaws, and negative repercussions as described in this chapter. (p.248) These have led to the termination of the TAF programme and its replacement by a more holistic programme in 2007. References Bibliography references: Agence France Presse (2005) Schools making fat students thin, but emotional burden is heavy, Agence France Presse, Singapore, Cheong, M.T., Cutter, J., & Chew, S.K. (2002) School based intervention has reduced obesity in Singapore. BMJ 324, 427. Davie, S. (2005) School link to eating disorders possible. The Straits Times, 16 May, p.1. Deurenberg-Yap, M., Schmidt, G., van Staveren, W.A., & Deurenbarg, P. (2000) The paradox of low body mass index and high body fat percentage among Chinese, Malays and Indians in Singapore. International Journal of Obesity 24, 1011–1017. Deurenberg-Yap, M., Chew, S.K., Lin, V.F., Tan, B.Y., van Staveren, W.A., & Deurenberg, P. (2001) Relationships between indices of obesity and its co-morbidities in multi-ethnic Singapore. International Journal of Obesity 25, 1554–1562. Fu, C.C., Chen, M.C., Li, Y.M., Liu, T.T., & Wang, L.Y. (2009) The risk factors for ultrasounddiagnosed non-alcoholic fatty liver disease among adolescents. Annals of the Academy of Medicine Singapore 38 (1), 15–21. Health Promotion Board (2006) Students Health Survey 2006 – highlights of findings among secondary students, Health Promotion Board, Singapore, . Ho, T.F. (2007) Childhood obesity in Singapore: epidemiology and clinical profile. Proceedings of 6th Annual Conference of the International Society of Behavioural Nutrition and Physical Activity, p. 101.

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Ho, T.F. (2009) Cardiovascular risk associated with obesity in children and adolescents. Annals of the Academy of Medicine Singapore 38 (1), 48–56. Ho, T.F., Tai, B.C., Lee, E.L., Cheng, S., & Liow, P.H. (2006) Prevalence and profile of females at risk of eating disorders in Singapore. Singapore Medical Journal 47(6), 499–503. Lee, W. (2003) Fighting fat: with TAF in Singapore. Diabetes Voice 48, 49–50. Lee, Y.S. (2009) Consequences of childhood obesity. Annals of the Academy of Medicine Singapore 38(1), 75–81. Lee, L., Kumar, S., & Lim, C.L. (1994) The impact of five-month basic military training on the body weight and body fat of 197 moderately to severely obese Singaporean males aged 17 to 19 years. International Journal of Obesity 18, 105–109. Lee, H.Y., Lee, E.L., Pathy, P., & Chan, Y.H. (2005) Anorexia nervosa in Singapore: an eight-year retrospective study. Singapore Medical Journal 46(6), 275–281. Loke, K.Y. (2008) 3rd College of Paediatrics and Child Health Lecture – the past, the present and the shape of things to come…. Annals of the Academy of Medicine Singapore 37(5), 429–434. Ministry of Defence, Singapore Research Project (1992). Nutritional and compositional study of SAF cookhouse food, Ministry of Defence, Singapore. Ministry of Health, Statistics (2009) Singapore health facts, Ministry of Health, Singapore, . Osman, D. (2009) Tubby kids – the new age disease. The Straits Times – Mind Your Body, 8 January, p. 14. PRI’s The World (2007) Global perspectives for an American audience, Obesity series part III: Singapore, PRI’s The World, United Kingdom, viewed 28 August 2009, . The National Bureau of Asian Research (2008) 2008 Case study, obesity prevention and control efforts in Singapore, report prepared by G. Soon, Y.H. Koh, M.L. Wong, & P.W. Lam, The National Bureau of Asian Research, United States of America, . The Associated Press (2007) Singapore to scrap anti-obesity program. The Washington Post, USA, viewed 28 August, 2009, . Walsh, B. (2004) Singapore shapes up. TIMEasia Magazine, 8 November. . Zeckhausen, D. (2008) Childhood obesity and the schools: shame hurts more than helps. Atlanta Journal – Constitution 3 September, .

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Asian adolescents in New Zealand—a health promotion approach

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Asian adolescents in New Zealand—a health promotion approach Shirin Foroughian

DOI:10.1093/acprof:oso/9780199572915.003.0022

Abstract and Keywords Obesity was seen as a non-Asian phenomenon in New Zealand in the past, but research in recent years is suggesting a different picture. Obesity is characterized by the excessive accumulation of adipose tissue to an extent that health is impaired. Obesity in children and adolescents may have serious consequences, ranging from short-term physical and psychosocial consequences to longterm consequences that persist into adulthood (e.g. type 2 diabetes). The global increase in obesity is also evident in Asian populations, especially in those who have migrated to Western countries with obesity-promoting environments. High energy foods and lack of exercise along with many other factors, contribute to this weight gain. Bearing in mind that the majority of these factors are modifiable risk factors, early detection and intervention are very important in preventing excessive weight gain in such populations. This chapter discusses weight issues among Asians in New Zealand, as well as risk factors and suggestions for community development-type approaches to health promotion.

Keywords: type 2 diabetes, Asians, overweight, New Zealand, children, culture, race, ethnic, community, public health

Chapter summary In the past, obesity was seen as a non-Asian phenomenon in New Zealand but research in recent years is suggesting a different picture. Obesity is characterized by the excessive accumulation of adipose tissue to an extent that health is impaired (International Obesity Task Force, 2009). Obesity in children and adolescents may have serious consequences ranging from short-term physical and psychosocial consequences to long-term consequences that persist into adulthood (e.g. Type 2 diabetes).

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Asian adolescents in New Zealand—a health promotion approach

The global increase in obesity is also evident in Asian populations, especially in those who have migrated to Western countries with obesity promoting environments. High energy foods and lack of exercise along with many other factors contribute to this weight gain. Bearing in mind that the majority of these factors are modifiable risk factors, early detection and intervention are very important in preventing excessive weight gain in such populations. In this chapter, weight issues and nutritional and exercise behaviours of young New Zealand Asians are briefly discussed and recommendation for prevention programmes are made.

Asians and weight related issues Compared to obesity studies conducted on other populations, there is very little study done on the issue of overweight/obesity in Asian adolescents. There is also little information on food habits and dietary changes of this population in their home countries where the prevalence of overweight and obesity has been growing in recent years. There are even fewer studies available that have investigated the weight status of Asians after resettlement in Western countries. Although little information is available, there is general consensus that Asian populations have also started experiencing lower rates of under-nutrition and higher rates of over-nutrition in both their home countries and in the migrated countries.

Study of Asian adolescents living in New Zealand The study, discussed in this chapter, was based on both quantitative (structured individual interviews and anthropometry measurements) and qualitative approaches (semi-structured interviews with focus groups) with adolescents of South Asian, East Asian and European ethnicities who lived and attended high schools in South Auckland (Foroughian, 2010). The findings suggested that being overweight is a concern faced by Asian adolescents at the same level as European adolescents. The results showed no significant difference in mean body mass index (BMI) or mean waist to height ratio (WHR) amongst the three ethnic groups; and (p. 251) no difference in Fat Mass between South Asian and European adolescents when using the same cut-off points for all ethnicities.

Causes of childhood obesity in Asian adolescents in New Zealand Risk factors There are a number of major factors suggesting problematic nutritional and exercise behaviours in Asian adolescents living in New Zealand. The principal ones of these are considered to be: missing breakfast or lunch, unhealthy sources of breakfast, morning tea or lunch (e.g. from school canteen), consumption of junk food such as chips, biscuits, chocolates, ice creams, pies, and noodles while at school or at home before dinner, purchasing food from school canteen or local neighbourhood stores, discrimination of culturally traditional foods at school, high consumption of sugary drinks, fried and fast foods, the influence of the Western dietary environment (for example having access to more food and more variety resulting in availability of more junk foods and soft drinks at home), lack of exercise and lack of opportunities to be active (e.g. at school or in the community), hours spent watching television or playing computer, video, or other electronic games, and cultural barriers to being physically active. Other factors include lack of school support and parental involvement for young people to be active and to eat healthy, as well as peer pressure, lack of knowledge of obesity risk factors, and lack of or misleading knowledge of healthy food and what to eat.

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Asian adolescents in New Zealand—a health promotion approach

Protective factors At the same time, there are a number of factors that play a protective role in maintaining a healthy weight. These protective factors include: having breakfast and lunch, healthy source of breakfast, morning tea and lunch (for example preparing and bringing food from home), having sandwiches and fruits at school, having a balanced dinner including traditional diets, walking or biking to school, doing sports at school, being involved in an organized or team sport, limiting TV viewing hours, being encouraged by parents, friends, schools, and teachers to be physically active and to eat healthy, and an accurate knowledge of obesity risk factors. Other factors Obesity is a multifactor issue; genetics, culture, change of environment, and many other factors have an impact on the weight status of young people. One possible determinant of obesity in Asian adolescents is explained by the Foetal Origins of Adult Disease (FOAD) hypothesis (Barker, 1999). FOAD suggests that if the pregnant mother is undernourished (the case for many Asian mothers), the foetus takes this information from its mother and sets its biology for an undernourished world (Tenhola et al., 2000). When born, the baby is not programmed for the kind of nutritional environment that is found in Western countries, for example the child is not set to cope with the kind of diets such as fast foods. In view of this information, it is timely to study and investigate the overweight and obesity status of this population and target them specifically in our planning, interventions, or policies in regard to obesity prevention and management. Considering the cost of obesity to the country and the quality of life of the young people who are overweight or obese and their families, we cannot afford to ignore a growing ethnic group in New Zealand in our attempts to promote the health of the population.

(p.252) Recommendations for prevention programmes Health promotion is both a philosophy and a set of approaches for improving people’s health including the prevention of obesity (Tse et al., 2006). As a philosophy, it signifies an empowering approach to health where people have control over the influences on their lives and health. In practice, health promotion is usually implemented as activities set within the context of an intervention (e.g. a project or a programme) (Tse et al., 2006). In this section of the chapter, an attempt is made to suggest a community development or health promotion approach based on the concept of empowerment targeted at young New Zealand Asians to improve their health in relation to weight related issues (i.e. obesity risk factors). It needs to be noted that this approach is not an ethnic analysis of community engagement but rather a general guideline. To deal with the issue of obesity in Asian adolescents, family, community, school, and government all have to play a role. This section incorporates recommendations made by young people themselves as to what can help them maintain a healthy lifestyle.

General framework for a health promotion approach In the Ottawa charter, health promotion is defined as ‘the process of enabling people to increase control over, and to improve, their health’ (World Health Organization, 1986). Therefore, a

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Asian adolescents in New Zealand—a health promotion approach

fundamental aspect of health promotion is that it aims to empower people to have more control over aspects of their lives, which affect their health. Green and Raeburn (1988) state that empowerment is defined in practical terms as involving control over life affairs, at the community, group, and personal levels. This control is established by a process of strength-building and is accomplished through people having access to the knowledge, skills, material and political resources. Professionals will always be required to assist with health promotion initiatives; however, the community – the Asian community in New Zealand in this case – can deal effectively with their own health promotion needs and activities if they have information and skills, financial, professional and organisational support, and resources. According to Raeburn and Rootman (1998), in health promotion, one is not dealing with people in a clinic or laboratory, but in real life, in the community; thus the community, rather than the individual, should be the centre of health promotion activities. Any health promotion programme dealing with Asian adolescents should consider having the community as its core focus (e.g. young Asians and their families) in order to be successful. An empowering community approach to health promotion requires full participation by community members in all aspects of intervention design, implementation, evaluation, and maintenance. Previous health promotion interventions in this regard have not been as effective, as they often did not include the participants in all aspects of intervention and hence the programmes have not been customized to the concerns and cultures of the participants (Chavez et al., 2004). In addition to ‘strengthening community action’, which is the main focus of the health promotion approach in this study, according to the Ottawa charter (1986), there are four other streams that a health promotion approach needs to take into account. These are building healthy public policy, creating supportive environments, developing personal skills, and reorienting health services. So although the focus is on the community, the influence and role of these other areas need to also be considered. In general, there are two types of health promotion approaches: the bottom-up approach (set by people themselves to identify issues they perceive as relevant), and the top-down approach (set by health promoters who have the power and resources to make decisions). In the case of (p. 253)

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Asian adolescents in New Zealand—a health promotion approach

Table 22.1 The PEOPLE system (Raeburn and Rootman, 1998) 1 Objectives & values statement

2 Needs/wishes assessment

3 Goal setting

4 Organizational and resource arrangements

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5 6 7 Action Reviews Periodic outcome assessment

Asian adolescents in New Zealand—a health promotion approach

promoting healthier lifestyle among young Asians, a combination of both approaches appears to be required. The first question that needs to be addressed is the readiness of the Asian community for any intervention programme. Based on the findings of several studies and consultations with the Asian community and cultural advisors, the Asian community is aware of the issue of obesity in young people and is ready to be involved in intervention programmes. The PEOPLE System (Table 22.1) suggested by Raeburn and Rootman (1998) seems to be an appropriate model to empower young Asians to live a healthier lifestyle in New Zealand. The PEOPLE System (Raeburn & Rootman, 1998), that is, the ‘Planning and Evaluation of People-Led Endeavours’, is a simple systems-oriented organizational framework designed to help community people plan, run, and evaluate their own community projects. The philosophy behind the PEOPLE system is People-centredness, Empowerment, Organizational and community development, Participation, Life quality and Evaluation. What makes the PEOPLE System work is the role of the ‘needs/ wishes assessment’ to find out what people really want for themselves, and what triggers motivation – this is the single most important element to understand when changing something as difficult as lifestyle. In this way, the approach is also certain to be culturally appropriate and effective for the Asian community, in addition to acknowledging Asian health beliefs. When working with the Asian community, the diversity of the ‘Asian’ adolescents should be recognized and taken into account, and the differences in ethnicity, religion, language proficiency, settlement history, socioeconomic status, and acculturation also need to be considered (Rasanathan et al., 2006). Also when recommending health promotion approaches, one needs to recognize the identity of ‘young Asians’ as ‘Western citizens’, as well as considering the role of traditional family cultures and practices, and find ways to support these practices to preserve the protective effects of their culture (Foroughian, 2005; Rasanathan et al., 2006).

Developing a health promotion approach for young Asians in New Zealand What follows in this chapter is the description of a health promotion model that involves the family and the community of young Asians based on the concept of empowerment and community development. It will offer two types of interventions suggested by a group of young Asians living in New Zealand who participated in 12 focus groups. These mainly include educational and physical activity interventions. The recommendations made by young people in the focus groups on what they saw was needed to initiate an effective behaviour and environment change programme will be taken as a hypothetical ‘needs/wishes assessment’ as a basis for suggesting a health promoting project. The approach suggested by this study to promote a healthier lifestyle in young New Zealand Asians in order to address the problem of obesity is a ‘family and community centred’ programme. In this approach, the families and communities are involved in identifying their needs, recognizing risk factors, planning, implementation, evaluation, and the maintenance of the programme. (p.254) The programme needs to be culturally specific and appropriate to address the needs of the Asian community in the new country of residence. It needs to consider the needs of the parents such as language, traditions, and values. It also needs to consider the needs of the

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Asian adolescents in New Zealand—a health promotion approach

young people, who, regardless of the years they have lived in the Western country, are trying to fit in with the wider community of young people. Another issue when working with Asian communities is the diversity of the communities and how scattered they are across New Zealand. This community consists of individuals from many different backgrounds, cultures, traditions, and educations who live in different geographical areas and have been living in the New Zealand with various durations. Regardless of these differences, most of the Asian community in New Zealand belong to one or more Asian organizations and can therefore be approached through these organizations in their public or networking meetings (Tse et al., 2006). Another strategy to approach the Asian community is through young people in the neighbourhood schools. Other ways of approaching the Asian community include ethnic newspapers, TV channels and radio stations (e.g. Indian or Chinese channels), temples (mainly for East Asians), mosques (mainly for South Asians), or churches. It needs to be emphasized that for these programmes to be successful in promoting healthier lifestyles and changing bad habits, the whole family needs to be involved and targeting either one of the parents or the young people is not enough. This does not mean that both groups (parents and children) have to be targeted through the same approach, but rather simultaneously. To begin the process, a model like the PEOPLE System could work very well with the Asian community. Once the community is approached an initial meeting can be set up to consult the objectives, values, needs, and wishes of the community in regard to the topic of a healthy lifestyle to prevent obesity. Identified and well-respected community members or community leaders could be trained to facilitate this session to tend to the language and cultural needs of the community, as well as giving the community the ownership of the programme. It is believed that the best results would be achieved with parents and young people initially meeting in separate groups. After the initial meetings, the interested members of the community can get together and set their goals (e.g. physical activity intervention such as a community space for young people to participate in sports after school), followed by planning the details and organizing resources that they may need (e.g. material and financial resources such as sports equipment and a trained coach). They will then put their plan into action and evaluate its effectiveness along the way. A programme like this will need many resources including the help of an expert to guide them through the process and to help the community to arrange the necessary resources for the implementation of the programme. This programme will take a considerable amount of time to be organized and to show its results but it is not appropriate for an expert to walk into a community and advise them on what they should be doing. In a situation like that, fewer members of the community will be engaged in the programme as the objectives of the programme may or may not address the needs and concerns of the community. In addition, once the expert is out of the picture the community is not able to sustain the programme. Therefore, it is crucial for the community to be involved in all aspects of the programme, regardless of the time and effort it will require.

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Asian adolescents in New Zealand—a health promotion approach

In this study, young people were asked to describe the kind of programmes that would make a difference in their lives in promoting healthier lifestyles to maintain a healthy weight. Among the many programmes suggested was a great emphasis on educational and physical activity interventions. The findings of earlier studies suggested that Asian adolescents have little knowledge of obesity risk factors. This was also supported by the findings of this study where the young people recognized that their knowledge of healthy foods and what to eat is poor and that they are faced with (p.255) confusing messages. Although education is not the only way to promote health, it is an important component of it and the community of interest (young Asians) believe that this is what they need. There are numerous ways that this can be done but it is important to provide these educational opportunities for both young people and their families to promote dietary changes and healthy food choices by providing information as well as practical advice. This can be achieved through schools and communities. Younger students attend compulsory health classes and they find it useful but as they get older they can choose the subjects they do each year and most of the Asian students do not select hospitality or physical education where they can receive nutritional information so they welcome seminars or workshops organized by the school that would give them practical nutritional information. However, Asian students emphasized that without their families involved in this process there would be very little change in their diet at home. Most schools offer weekly evening classes for adults in the community on various topics and nutrition could be one of them where families could be assisted in making healthier food choices. These classes could teach parents and young people how to cook any kind of food (traditional or Western) with healthy substitutes and techniques. It could take people to a supermarket and teach them how to shop healthy on a low budget, how to read nutrition information on food labels, and determine, for example, the fat and sugar content of food. It can encourage families to have vegetable gardens in their homes. The classes could also teach people about appropriate portion sizes, good and bad fats, and any other simple yet valuable information that would help them make better choices. The point that is really important to be mentioned here, and it was emphasized by young people as well, is that they need nutritional education but they are looking for reliable, clear, simple, and practical information. They also want information that is positive, encouraging, and motivational. In other words, young people do not like programmes with an emphasis on weight loss but rather on having a healthy lifestyle and adding to the quality of life. What is needed here is development of a curriculum that addresses all these needs to be used across the country in different communities. Members of the Asian communities should be involved in the production of this curriculum to make sure the content is what they need, practical and culturally appropriate. Although the emphasis here is on the food, obesity is influenced by many other factors, so it would be useful to include non-nutrition information that indirectly affects weight status in these classes and workshops. Topics such as stress management (relationship between food and mood), time management (how to avoid the use of fast foods and enjoy home meals with busy lifestyles), parenting skills (how to involve children in all aspects of life including shopping and cooking), and budgeting.

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Asian adolescents in New Zealand—a health promotion approach

In relation to physical activity interventions, young people mentioned that there are not many opportunities for them to be physically active during school hours or in the community after school and on the weekends. In addition to this, some girls are faced with cultural constraints that prevent them from being involved in team and organized sports. It is evident from the findings of this study that those who were involved in organized sports were the ones getting enough exercise during the week but the opportunity is not present for everyone. As young people recognize that they need more exercise and they want to be active, the solution is as simple as providing accessible and affordable sports opportunities for young people at school and in the community. This could even include dance classes or active games that involve the whole family. People who are active are not only physically healthier, but are also happier; so involving the whole family has benefits beyond decreasing the prevalence of obesity and its associated health problems. In this regard, the community can play a big role by directing its resources towards providing opportunities for young people and their families to be physically active. Role models could also be utilized to get people involved in these activities. Another way of engaging the Asian community in sport activities, as mentioned by young people, is through competitions with small rewards. (p.256) As mentioned before, these programmes (educational and physical activity interventions) need to be developmentally appropriate. The aim is not to limit young people’s food intake, but rather to encourage healthy eating and exercise habits. In addition, young people need to be motivated to change and sustain the positive behaviour changes, and they are motivated when the programme is fun, interesting, enjoyable, and it involves friends and good role models. There would need to be behavioural strategies modelled, discussed, and rehearsed. There would be a need for regular follow-ups, but the sustainability of the results and long-term behaviour change will mostly depend on the family and the community. On-going community groups can provide the necessary support and keep the members of the community motivated. This could, for example, include community action days or health days, where the community gets together to follow-up and evaluate the existing programmes, or to organize physical and recreational activities for the whole community, but with the main focus on young people. The community is the main driver and can take care of its own affairs in this model, but no doubt they will need appropriate knowledge, skills, and money to undertake such projects. The community alone cannot resource such a programme, and other organizations and service providers need to assist them by increasing the availability of resources. These may include supporting and encouraging the existing activities, financial support, culturally appropriate support (e.g. providing sports facilities for girls and more access to any type of physical activity for everyone), new policies and legislations, etc. Schools also play a big role in making these experiences easier by teaching healthy lifestyles, teachers becoming role models, and by providing a more supportive environment for young people (e.g. monitoring the school canteen). The community working together with other professionals or organizations need strong communication and collaboration in setting priorities, making decisions, planning strategies, and implementing them. In addition to ‘strengthening community action’ and ‘developing personal skills’ with a strong focus on empowerment, which has been discussed as the main focus of the health promotion

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Asian adolescents in New Zealand—a health promotion approach

approach in this study, the Ottawa charter (1986) offers three other streams that a health promotion approach needs to take into account: Building healthy public policy This includes putting the health of the ever-growing Asian community of New Zealand on the agenda of policy makers in all sectors; for example, Ministry of Health, Ministry of Sports and Recreation, and Ministry of Education; and to include and target Asian community in obesity related policies, guidelines, and interventions. Creating supportive environments The links between people’s health and their environment comprise the basis for a socioecological approach to health. Health promotion creates living conditions that are conducive to making healthy food choices and being active easy and stimulating. This could include monitoring the price and availability of healthy foods at school canteens and dairies close to schools, monitoring media by eliminating harmful advertisements and increasing reliable educational documentaries, making sports opportunities available and affordable. Reorienting health services The responsibility for health promotion is shared by individuals, community groups, health professionals, health service institutions, and the government, and needs to move in a health promotion direction, beyond providing clinical and curative services.

(p.257) Conclusions In summary, to empower and improve the health of young people to maintain a healthy lifestyle, a ‘family and community centred’ model with the concept of empowerment at its core is suggested. This model would include educational and physical activity interventions for young people and their families. The programme needs to be enjoyable, encouraging, and culturally appropriate. For the programme to be successful, communication and collaboration between community, health professionals, and service providers and government sectors are vital. References Bibliography references: Barker, D.J. (1999) Fetal origins of cardiovascular disease. Annals of Medicine 31(Suppl. 1), 3–6. Chavez, V., Israel, B., Allen, A.J., et al. (2004) A bridge between communities: video-making using principles of community-based participatory research. Health Promotion Practice 5, 395– 403. Foroughian, S. (2005) From kebab and kufta to fish and chips: a qualitative study of overweight and obesity issues in young refugees in New Zealand. University of Auckland. Foroughian, S. (2010) A quantitative and qualitative study of lifestyle and obesity in Asian adolescents in New Zealand. University of Auckland. Green, L.W. & Raeburn, J.M. (1988) Health promotion. What is it? What will it become? Health Promotion International 3(2), 151–159.

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Asian adolescents in New Zealand—a health promotion approach

International Obesity Task Force (2009) Global childhood overweight [online]. [Accessed 9 November 2009]. Raeburn, J.M. & Rootman, I. (1998) People-centred health promotion. John Wiley & Sons. Rasanathan, K., Ameratunga, S., Chen, J., Robinson, E., Young, W., Wong, G., et al. (2006) A health profile of young Asian New Zealanders who attend secondary school: findings from Youth 2000. Auckland. Tenhola, S., Martikainen, A., Rahiala, E., Herrgard, E., Halonen, P., & Voutilainen, R. (2000) Serum lipid concentrations and growth characteristics in 12-year-old children born small for gestational age. Pediatric Research 48, 623–628. Tse, S., Laverack, G., Foroughian, S., & Jackson, N. (2006) Community engagement for health promotion activities to reduce injuries among Chinese Asian people in New Zealand. Prepared for Accident Compensation Corporation, Auckland. World Health Organization (1986) The Ottawa Charter for health promotion. Ottawa: World Health Organization/Canadian Public Health Association.

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The role of health professionals

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

The role of health professionals Kelley DeVane Hart Bonnie A. Spear

DOI:10.1093/acprof:oso/9780199572915.003.0023

Abstract and Keywords The past decade has witnessed a phenomenal increase in the awareness and concerns over childhood obesity prevention and intervention. Many view the health care provider as ‘jumping onboard’ too little and too late, especially in the area of prevention. Numerous population-level studies have demonstrated the link between early life events and the occurrence of many common chronic diseases. For example, malnutrition in early gestation or rapid weight gain in a low birth weight infant increases the odds of childhood obesity. This chapter discusses the Life Course Perspective which focuses on health being a developmental process occurring throughout the lifespan and life stage (developmental periods). There are critical periods that appear to have greater impact than others. The early part of the life span is when health programming is more intense and prevention has the greatest potential impact. The chapter also discusses how health professionals can be aware of early risk factors that increase the risk for childhood obesity and provide early intervention. Because health care professionals see patients over numerous visits, they possess the knowledge, skills, and tools needed to advise patients about appropriate weight.

Keywords: prevention, low birth weight, life span, health programming, children, diagnosis, measurement, interpretation, public health professionals, physician

Chapter summary The past decade has witnessed a phenomenal increase in the awareness and concerns over childhood obesity prevention and intervention. Many view the health care provider as ‘jumping onboard’ too little and too late especially in the area of prevention. Numerous population-level studies have demonstrated the link between early life events and the occurrence of many

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The role of health professionals

common chronic diseases. For example, malnutrition in early gestation or rapid weight gain in a low birth weight infant increase the odds of childhood obesity. This chapter discusses the Life Course Perspective, which focuses on health being a developmental process occurring throughout the life span and life stages (developmental periods). There are critical periods that appear to have greater impact than others. The early part of the life span is when health programming is more intense and prevention has the greatest potential impact. This chapter also discusses how health professionals can be aware of early risk factors that increase the risk for childhood obesity and provide early intervention. Because health care professionals see patients over numerous visits, health care professionals possess knowledge, skills, and tools needed when advising patients about appropriate weights. As identified earlier in this book, the prevalence of childhood obesity across all age and racial groups is staggering. The role of the health care provider in preventing childhood obesity can be daunting. The purpose of this chapter is to identify current recommendations for the clinician and to address ways in which the health care professional can champion policies or initiatives that promote healthy weights among children and adolescents.

Childhood obesity and the social ecological model Health care professionals are well aware that a multitude of factors have led to the childhood obesity problem of today. To begin to identify all the factors associated with childhood obesity would be monumental. One way to condense these factors is by viewing them through the lens of the Social Ecological Model (McLeroy et al., 1988). This ecological model focuses attention on both individual and environmental factors. The model identifies five spheres of influence, which are: ◆ Intrapersonal factors – characteristics of the individual such as knowledge, attitudes, behaviour, genetics. Health Provider’s role (examples): ● Professionals should routinely track BMI, ● Offer relevant evidence-based counseling and guidance ● Provide early intervention for at-risk children/families (e.g., re-feeding in low birth weight infants, early BMI rebound, parental obesity) ● Improve behavioural counseling skills (e.g., motivational interviewing techniques) ● Provide for staff development (e.g., to indentify high risk, accurately measure children) (p.259) ● Continue to push for reimbursement/payments for preventive counseling ● Follow-up with more frequent visits for at-risk families ◆ Interpersonal factors – formal and informal social network and social support systems, including family and friend networks,

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The role of health professionals

Provider’s role (examples): ◆ Helping families find community programmes/services ◆ Helping families identify support systems ◆ Using behavioural counseling skills to involve entire family, including extended family and child care providers ◆ Institutional factors – social institutions with organizational characteristics and formal and informal rules as well as regulations for operation. Provider’s role (examples): ● Work with schools to ensure healthy eating and physical activity environments (e.g., nutrition programmes, school vending/food sales, regular physical education programmes). ● Serve on school committees to promote prevention activities ● Work with professional organizations to disseminate evidence-based clinical guidance and establish programmes on obesity prevention ◆ Community factors – relationships among organizations, institutions, and informant networks within defined boundaries. Provider’s role (examples): ● Involve with communities to ensure the following: ■ Design of the neighbourhoods encourages physical activity ■ Community facilities are available to children and youth for recreational activities ■ Children can pursue sports and other active-leisure activities without concerns for safety ■ Healthy food choices available in local stores at reasonable prices. ◆ Public policy – local, state, and national laws and policies: factors which support and maintain health behaviours. Provider’s roles (examples): ◆ Support policies that provide for healthy school environments ◆ Support policies that provide for safe and convenient community built environments Intrapersonal factors Intrapersonal factors are typically those that involve an individual. Intrapersonal factors would include a genetic predisposition to obesity, attitudes toward healthy eating and physical activity behaviours, and health knowledge and behaviours.

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The role of health professionals

In 2007 an expert committee designed recommendations for the prevention and treatment of childhood obesity based on evidence-based analysis. The majority of those recommendations focus on intrapersonal factors. Those recommendations (found in Table 23.1) are placed into three categories based on: consistent evidence, mixed evidence, and suggestions. Consistent evidence indicates that multiple studies found an association between the recommended behaviour and obesity risk or energy balance. Those actions include limiting intake of sugarsweetened beverages, limiting television viewing and other screen time activities to not more than 2 hours per day, removing any television or other screen from the child’s primary sleeping area, eating breakfast (p.260) daily, and limiting portion sizes. Mixed evidence was found in regard to the intake of fruits and vegetables indicating that some studies suggested evidence for weight or energy balance whereas others did not show significant findings. However, the committee does encourage the consumption of the recommended intake of fruits and vegetables. The final recommendations are based on expert opinion by the committee. These include consuming a diet rich in calcium, eating an adequate intake of fiber, consuming a diet with balanced macronutrients, promoting moderate to vigorous activity daily for a minimum of 60 minutes, and limiting intake of energy dense foods. For infants, the committee recommends exclusive breastfeeding until 6 months of age and maintaining breastfeeding after the introduction of solid food until 12 months of age or greater (Barlow and the Expert Committee, 2007). (p.261)

Fig. 23.1 Illustrates the social ecological model and childhood obesity. Adapted from McElroy KR, Bibeau D, Steckler A, and Glanz K (1988). A Perspective on Health Promotion Programs. Health Education Quarterly 15: 351–377, by permission of SAGE Publications.

Table 23.1 Expert committee recommendations for evidence-based target behaviours

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The role of health professionals

Strength of evidence

Target behaviour

Consistent evidence – multiple studies showed an association between the recommended behaviour and obesity risk or energy balance

◆ Limiting consumption of sugar-sweetened beverages, ◆ Limiting television and other screen time to 2 hours or less for children 2 years of age or oldera, and removing televisions and other screens from children’s primary sleeping area ◆ Eating breakfast daily ◆ Limiting eating out at restaurants, particularly fast food restaurants ◆ Encouraging family meals in which parents and children eat together ◆ Limiting portion size

Mixed evidence – some studies suggested evidence for weight or energy balance benefit but others did not show significant associations or studies were few in number or small in size

◆ Encouraging consumption of diets with recommended quantities of fruits and vegetables

Suggestions – the expert committee believes these recommendations could support the achievement of healthy weight

◆ Eating a diet rich in calcium ◆ Eating a diet high in fiber ◆ Eating a diet with balanced macronutrientsb ◆ Encouraging exclusive breastfeeding to 6 months of age and maintenance of breastfeeding after introduction of solid food to 12 months of age and beyondc ◆ Promoting moderate to vigorous physical activity for at least 60 minutes each dayd ◆ Limiting consumption of energy-dense foods

Data from Barlow SE and the Expert Committee (2007). Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 120, S164–S192. a

The American Academy of Pediatrics recommends no television before 2 years of age, and no more than 2 hours per day for children ages 2 years and older (American Academy of Pediatrics, 2001). b

Energy from fat, carbohydrates, and protein in proportions for age, as recommended by Dietary Reference Intakes (US Department of Health and Human Services, 2005).

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c

Consistent with recommendations from the American Academy of Pediatrics (Krebs & Jacobson, 2003, Owen et al., 2005). d

Consistent with guidance provided by evidence-based review (Strong et al., 2005).

In the clinical setting, a staged approach to weight management has been proposed (Spear et al., 2007). At least yearly, BMI calculation and plotting on the appropriate growth curve would take place for each patient. Identification of weight category would be made based on BMI-forage for gender with categories of underweight (〈 5th percentile), healthy weight (5th–84th percentile), overweight (85th–94th percentile), and obese (≥ 95th percentile). For children with BMI-for-age percentiles at or above the 85th percentile, a medical assessment is conducted to assess for presence of familial obesity, diabetes, and/or cardiovascular disease. Based on clinical judgement, laboratory evaluations may be completed to assess for obesity-related conditions. A dietary, physical activity, and sedentary behaviour assessment is conducted to determine what behaviours may be contributing to an increased BMI (Barlow & Spear, 2010). The staged approach (outlined in Table 23.2) identifies the recommended behaviours as well as the course of action for each stage. In the following, stages 1 and 2 are designed to be provided in the primary care provider’s office. In stage 1, Prevention Plus, overweight and obese children and adolescents, along with their families, work to develop healthy eating and physical activity habits, which aid in obesity prevention. (p.262) Table 23.2 Staged approach for treatment of childhood and adolescent obesity Stage

What: recommended behaviours for child/ adolescent and family

How: setting and staff for intervention

When

Stage 1 prevention plus

5+ fruits and vegetables 〈 2 hours/day screen time ≥ 1 hour/day physical activity Reduce/eliminate sugar-sweetened beverages Eating behaviours (e.g. three meals a day, family meals, limit eating out) Family-based change

Office-based Trained office support (e.g. physician, pediatric nurse practitioner, nurse, physician assistant) Scheduled follow-up visits

Frequency of visits based on readiness to change and behavioural counseling approaches Reevaluate in 3 to 6 months Advance to next level depending on response and interest

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Stage

What: recommended behaviours for child/ adolescent and family

How: setting and staff for intervention

When

Stage 2 structured Develop plan for weight family and/or management adolescent to include: More structure (timing and content) of daily meals and snacks Balanced macronutrient diet Reduced screen time to 〈1 hour/day Increased time spent in physical activity Monitoring taught to improve success (e.g. logs of screen time, physical activity, dietary intake, or dietary patterns)

Office-based (dietitian, physician, nurse) trained in: Assessment techniques Motivational interviewing/ behavioural counseling Teaching parenting skills and managing family conflict Food planning Physical activity counseling Support from referrals

Monthly visits tailored to child/adolescent and family Advance if needed or if no improvement after 3 to 6 months (improvement = weight maintenance or BMI deflection downwards)

Stage 3 comprehensive multidisciplinary intervention

Structured behavioural programme (e.g. food monitoring, goal setting contingency management) Improved home food environment

Multidisciplinary team (includes dietitian and counselor or behaviourist, with medical oversight)

Weekly for 8 to 12 weeks, then monthly If no improvement after 6 months (improvement = weight loss or BMI deflection downward) then: ◆ For ages 2 to 5 years remain in stage 3 with continued support

Structured dietary and physical activity interventions designed to result in negative energy balance Strong parental/family involvement especially 〈 age 12 years

Dedicated pediatric weight management programme or dietitian and behavioural counselor plus structured activity programme

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◆ For ages 6 to 11 years if 〉 99th percentile* and a comorbidity, consider stage 4 ◆ For ages 12 to 18 years if 〉 99th percentile* with a comorbidity or with 〉 6 months of no weight loss in stage 3, consider stage 4

The role of health professionals

Stage

What: recommended behaviours for child/ adolescent and family

How: setting and staff for intervention

When

Stage 4 tertiary care intervention

Continued diet and activity behavioural counseling plus consider more aggressive approaches, such as medication, surgery, or meal replacement

Pediatric weight management centre operating under established protocols Multidisciplinary team

According to protocol

Source: Data from Spear et al. (2007). *There is not a consensus on a definition of severe obesity. The expert committee suggested use of 99th percentile based on cut-points defined by Freedman et al. from NHANES data. These cut-points may be imprecise, but children with BMI at or above this level have higher medical risk and therefore intervention is more urgent. (p.263) (p.264) In stage 2, Structured Weight Management, more support is given to guide the patient and family towards the desired behaviours. Stage 3, the Comprehensive, Multidisciplinary Intervention, requires a strong commitment from patients and families as the programme intensity and frequency of visits increases. Finally, stage 4, the Tertiary Care Intervention, may be considered for severely obese adolescents. Within this stage, intensive interventions such as medications, meal replacements, or surgery may be considered. Interpersonal factors Two of the recommendations presented by the expert committee pertain to interpersonal factors, or those behaviours that occur between two or more people. Limiting the frequency of eating out at restaurants, particularly fast food restaurants, and encouraging family meals are recommendations that were presented with consistent evidence (Barlow and the Expert Committee, 2007). Concerning dietary intake, parents may believe that rigidly controlling a child’s intake may lead to healthier eating practices. Although this monitoring may produce short-term benefits, the long-term effect may actually encourage the development of obesity by disrupting the child’s self-regulation of energy intake (Faith et al., 2004) and promoting a preference for ‘forbidden’ foods (Fisher & Birch, 1999). In addition, longitudinal studies have shown that when greater parental control is exerted, the children’s diets are lower in fruit and vegetable intake (Galloway et al., 2005) and higher in dietary fat (Lee & Birch, 2002). Parents should be encouraged to provide access to healthy foods and to be good role models of healthy behaviours while allowing the child to exert autonomy in selection and amount of food eaten. Institutional factors The American Academy of Pediatrics suggests that physicians take the advocates’ role in impacting school policies, which could reach countless children by lobbying for adequate health

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education and physical education. Similarly, all health care professionals can promote beneficial change by advocating for healthy food choices in schools and child-care facilities, supporting the availability of school playgrounds after school hours, and petitioning for safe walking routes to schools. Professionals can also work within their professional organizations to promote obesity prevention activities. Community factors Improvement of community factors that impact childhood obesity can occur when health care professionals support campaigns for sidewalks, bike trails, playgrounds, and recreational facilities in the community. Efforts can be made to encourage increased access to healthy food options, such as the initiation of a farmer’s market.

Public policy Health care professionals can join in efforts to create public policies, which make healthy weights more achievable such as requiring that children be enrolled in physical activity in schools from kindergarten to grade 12 and the revision of agricultural policies, which would make healthy food options more affordable. Within the realm of public policy and social structure, it is imperative for the health care professional to recognize that cultural and ethnic influences impact health behaviours related to childhood obesity (Burnet et al., 2008; Kaufman & Karpati, 2007; Kumanyika, 2008; Larson & (p.265) Story, 2009). Developing cultural competencies are necessary for health care professionals for encouraging behaviours, which are associated with achieving a healthy weight.

Conclusions The role of the provider in the prevention of childhood obesity has to be multi-factorial. The provider needs to take the lead at the individual level. But the individual needs to have knowledge about community programmes. Providers can bring credibility and help communities to provide evidence-based programming in the prevention and intervention in childhood obesity. Providers need to look at childhood obesity from a global perspective and provider leadership in the development of comprehensive programming to decrease the rate of childhood obesity. References Bibliography references: American Academy of Pediatrics, Committee on Public Education (2001) Children, adolescents, and television. Pediatrics 107, 423–426. Barlow, S.E. & the Expert Committee (2007) Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 120, S164–S192. Barlow, S.E. & Spear, B.A. (2010) Childhood obesity. In K. Holt & N.H. Wooldridge (Ed.) Bright futures in practice: nutrition, 3rd edition. Elk Grove Village, IL, American Academy of Pediatrics.

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Burnet, D.L., Plaut, A.J., Ossowski, K., et al. (2008) Community and family perspectives on addressing overweight in urban, African-American youth. Journal of General Internal Medicine 23(2), 175–179. Faith, M.S., Scanlon, K.S., Birch, L.L., Francis, L.A., & Sherry, B. (2004) Parent–child feeding strategies and their relationships to child eating and weight status. Obesity Research 12(11), 1711–1722. Fisher, J.O. & Birch, L.L. (1999) Restricting access to palatable food affects children’s behavioral response, food selection and intake. American Journal of Clinical Nutrition 69, 1264– 1272. Freedman, D.S., Mei, Z., Srinivasan, S.R., Berenson, G.S., & Dietz, W.H. (2007) Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. Journal of pediatrics 150, 12–17. Galloway, A.T., Fiorito, L., Lee, Y., & Birch, L.L. (2005) Parental pressure, dietary patterns, and weight status among girls who are ‘picky eaters’. Journal of the American Dietetic Association 105(4), 541–548. Kaufman, L. & Karpati, A. (2007) Understanding the sociocultural roots of childhood obesity: food practices among Latino families of Bushwick, Brooklyn. Social Science and Medicine 64, 2177–2188. Krebs, N.F. & Jacobson, M.S. (2003) Prevention of pediatric overweight and obesity. Pediatrics 112, 424–430. Kumanyika, S.K. (2008) Environmental influences on childhood obesity: ethnic and cultural influences in context. Physiology and Behavior 94, 61–70. Larson, N. & Story, M. (2009) A review of environmental influences on food choices. Annals of Behavioral Medicine 38 (Suppl. 1), S56–S73. Lee, Y. & Birch, L.L. (2002) Diet quality, nutrient intake, weight status, and feeding environments of girls meeting or exceeding the American Academy of Pediatrics recommendations for total dietary fat. Pediatrics 54(3), 179–186. McLeroy, K.R., Bibeau, D., Steckler, A., & Glanz, K. (1988) An ecological perspective on health promotion programs. Health Education Quarterly 15(4), 351–377. Owen, C.G., Martin, R.M., Whincup, P.H., Smith, G.D., & Cook, D.G. (2005) Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics 115, 1367–1377. Spear, B.A., Barlow, S.E., Ervin, C., et al. (2007) Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics 20(4), s254–s288.

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Strong, W.B., Malina, R.M., Blimkie, C.J. et al. (2005) Evidence based physical activity for school-age youth. Journal of Pediatrics 146, 732–737. US Department of Health and Human Services, US Department of Agriculture (2005) Dietary Guidelines for Americans, 2005, 6th edition. Washington, DC: Government Printing Office.

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Striving to prevent obesity and other weight-related problems in adolescent girls: The New Moves approach

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Striving to prevent obesity and other weight-related problems in adolescent girls: The New Moves approach Dianne Neumark-Sztainer Colleen Flattum Shira Feldman Christine Petrich

DOI:10.1093/acprof:oso/9780199572915.003.0024

Abstract and Keywords New Moves was developed as a school-based obesity prevention intervention for adolescent girls. The program underwent extensive pilot-testing with funding from the American Heart Association. It is being evaluated in a group-randomized controlled trial with six intervention and six comparison schools; the study is being funded by the National Institutes of Health. The intervention targets inactive adolescent girls at risk for obesity and other weight-related problems. New Moves addresses risk factors of relevance to a broad spectrum of weight-related problems. This chapter describes the New Moves intervention, with particular attention given to a few key messages and intervention strategies that have relevance not only to obesity, but also to other weight-related problems. It begins with an overview of the New Moves program. This section is followed by more detailed descriptions of the New Moves physical education component, which was designed to help girls feel comfortable being physically active regardless of their shape, size, or skills; the non-dieting approach to healthier eating; and strategies used to help the girls to view their bodies more positively. The chapter concludes by considering the importance of integrating programs such as New Moves into existing institutions, and developing programs that address a broad spectrum of weight-related problems for different types of populations.

Keywords: New Moves, adolescent girls, American Heart Association, obesity, children, intervention, eating disorders, prevention, education

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Striving to prevent obesity and other weight-related problems in adolescent girls: The New Moves approach

Chapter summary New Moves was developed as a school-based obesity prevention intervention for adolescent girls. The programme underwent extensive pilot-testing with funding from the American Heart Association (Neumark-Sztainer et al., 2003). It is further being evaluated in a group-randomized controlled trial with six intervention and six comparison schools; the study is being funded by the National Institutes of Health (Neumark-Sztainer et al., Grant ROIDK063107). The intervention targets inactive adolescent girls who are at risk for obesity and other weightrelated problems. New Moves addresses risk factors of relevance to a broad spectrum of weightrelated problems. This chapter includes a description of the New Moves intervention, with particular attention given to describing a few key messages and intervention strategies that have relevance not only to obesity, but also to other weight-related problems. First, an overview of the New Moves programme is provided. This section is followed by more detailed descriptions of: 1) the New Moves physical education component, which was designed to help girls feel comfortable being physically active regardless of their shape, size, or skills; 2) the non-dieting approach to healthier eating; and 3) strategies used to help the girls to view their bodies more positively. We conclude by considering the importance of integrating programmes such as New Moves into existing institutions and developing programmes that address a broad spectrum of weight-related problems for different types of populations.

Introduction Obesity among adolescents is a significant public health problem, given its high prevalence (Ogden et al., 2006) and potential physical consequences (Daniels, 2006). Obesity may also be associated with harmful psychosocial and behavioural consequences, in part due to the difficulties of living within a society that values thinness (Puhl & Latner, 2007). Because of particularly strong social pressures on girls to be thin, overweight adolescent girls are at high risk for body dissatisfaction and unhealthy weight control behaviours. For example, in Project EAT (Eating Among Teens), a large population-based study on adolescents’ eating behaviours and weight issues, 66% of overweight adolescent girls indicated low levels of body satisfaction and 76% reported the use of unhealthy weight control behaviours in the past year (Neumark-Sztainer et al., 2002). Research further shows that adolescent girls who have high levels of body dissatisfaction and engage in unhealthy weight control behaviours are at increased risk for both obesity and eating disorders over time (Neumark-Sztainer et al., 2007; Stice, 2002; Stice, 2001; The McKnight (p.270) Investigators, 2003; van den Berg & NeumarkSztainer, 2007). For example, in Project EAT, girls who reported the use of unhealthy weight control behaviours were at nearly three times the odds for being overweight 5 years later, as compared to girls not engaging in weight control behaviours, in analyses adjusted for baseline weight status (odds ratio = 2.7; p = 0.004) (Neumark-Sztainer et al., 2006b). These findings suggest that obesity prevention interventions for adolescent girls need to help girls feel better about their bodies, avoid unhealthy weight control behaviours, and find appropriate, and more helpful, alternative behaviours for preventing overweight. Girls with high levels of body dissatisfaction, or low levels of confidence in their physical activity skills, may be less likely to engage in physical activity (Allison et al., 1999; Neumark-Sztainer et al., 2006a; Sallis et al., 1999), which may be due to their discomfort in being physically active within public settings. Adolescent girls show a steep decline in physical activity during

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Striving to prevent obesity and other weight-related problems in adolescent girls: The New Moves approach

adolescence (Caspersen et al., 2000; Kimm et al., 2000; Trost et al., 2002); therefore, obesity prevention interventions need to find ways to help girls be physically active. In designing interventions with a physical activity component, it may be important to address body image concerns and provide environments in which all girls, regardless of their physical activity skill level, feel comfortable being physically active. In developing interventions aimed at the prevention or reduction of obesity, it can be useful to think in terms of a broad spectrum of weight-related problems, which includes unhealthy weight control behaviours, body dissatisfaction, inadequate physical activity, and irregular eating patterns such as binge eating, in addition to obesity (See Fig. 24.1). Although this type of spectrum has potential relevance for all groups, regardless of age, gender, or cultural background, it has particular relevance for adolescent girls, who are the focus of this chapter, given the pressures they experience to conform to a thin ideal. It is important to think broadly about risk and protective factors for the spectrum of weight-related problems in adolescent girls and address factors such as societal pressures to be thin, alternatives to dieting, healthful ways of dealing with stress, and obstacles to living a physically active lifestyle.

(p.271) The New Moves programme: an overview The underlying philosophy of the New Moves programme is to provide a setting that strives to help girls feel good about themselves so that they will want to nurture their bodies through physical activity and healthful eating on a long-term basis. New Moves is guided by Social Cognitive Theory (Bandura, 1986; Baranowski et al., 2002) and targets socio-environmental factors (e.g., peer support), personal factors (e.g., body image), and behavioural factors (e.g., goal setting) in order to bring about changes in eating behaviours and physical activity (Fig. 24.2).

Fig. 24.1 A spectrum of eating and exercising behaviours from healthy to disordered. Reproduced from Neumark-Sztainer, D. (2005), I'm, Like, So Fat!: Helping your teen make healthy choices about eating and exercise in a weight-obsessed world. The Guilford Press, with permission.

New Moves aims to: 1) bring about positive change in physical activity and eating behaviours to improve weight status and overall health; 2) help girls function in a thin oriented society and feel good about themselves; and 3) help girls avoid unhealthy weight control behaviours. The New Moves intervention has eight behavioural objectives for girls: 1) be physically active at least 1 hour each day; 2) limit television/video watching to no more than 1 hour a day; 3) increase

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Striving to prevent obesity and other weight-related problems in adolescent girls: The New Moves approach

(p.272) fruit and vegetable intake; 4) limit soft drinks and other sweetened beverages; 5) eat breakfast every day; 6) pay attention to hunger and satiety cues; 7) avoid unhealthy weight control behaviours; and 8) focus on positive traits. The New Moves intervention includes different integrated components to address relevant socio-environmental, personal, and behavioural factors in order to help the girls achieve these eight behavioural objectives (Neumark-Sztainer et al., 2008). New Moves includes an intensive intervention phase, in which girls participate in daily activities as part of their physical education class, and a maintenance phase, which includes weekly meetings over lunch at school. Individual sessions, which incorporate motivational interviewing techniques (Flattum et al., 2009; Resnicow et al., 2006; Rollnick & Miller, 1995) are offered throughout both phases. A minimal parent outreach component is also included, which spans across both the intervention and maintenance phases.

Fig. 24.2 New Moves theoretical model of change based on social cognitive theory. Reproduced from Neumark-Sztainer, D. et al. (2008), with permission of the American Academy of Paediatrics.

The New Moves programme takes place in an all-girls physical education class, which counts towards the girls’ high school physical education requirement. The class includes physical education, nutrition, and social support components. Physical education teachers lead the physical education Section 4 days a week over one semester. During the study period, in which the New Moves programme was being evaluated, physical education teachers participated in a full-day teacher training, led by New Moves intervention staff that focused on understanding the profile of a New Moves girl, providing a variety of lifestyle physical activities suitable for girls of different shapes, sizes, and skill levels, reinforcing the girls’ efforts via positive feedback, and creating a fun and safe environment. One class session per week is devoted to either nutrition or social support sessions. The nutrition component takes a non-dieting approach towards improving dietary intake and eating patterns. Building a positive self-image and self-empowerment are the main goals of the social support sessions. Classroom time during nutrition and social support sessions includes group discussion and activities on how teenagers can fuel their bodies through healthy eating as well as issues that affect teenagers’ lives such as how to create time for things they want to do and how to deal with stressors and pressures that young women face today. During the study period, these sessions were taught in a classroom setting by New Moves staff. However, following the study period, schools that have adopted the programme have chosen different methods for

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Striving to prevent obesity and other weight-related problems in adolescent girls: The New Moves approach

teaching these sessions, including having them taught by the physical education teacher, a school health care provider, or a university nutrition student. Concepts and teaching strategies from both the obesity and eating disorder fields are incorporated into the intervention given adolescent girls’ risk for a range of weight-related problems. Intervention messages are addressed in the participant workbook, Girl Pages, and throughout the programme components. The Girl Pages contains information on each week’s topic plus additional information such as recipe cards, cut-out fit cards with various exercises, and resources for being physically active in the community. Each week’s lesson in the Girl Pages is divided into three sections, Be Fit (physical activity), Be Fab (social support and selfempowerment), and Be Fueled (nutrition). The Girl Pages workbook is designed in a teenage magazine style. Active and experiential learning form the basis for programme activities. All intervention materials are available at www.newmovesonline.com.

Enhancing physical activity: Be Fit New Moves aims to help girls feel comfortable being physically active and meet the Healthy People 2010 goal for moderate to vigorous physical activity of at least 1 hour a day (U.S. Department of Health and Human Services PHS, 2000). The physical activity component section of New Moves, Be Fit, is focused on increasing physical activity in a fun, supportive environment and working towards leading a more active lifestyle outside of class. (p.273) Be Fit is taught by a physical education teacher trained in the New Moves philosophy. Teachers are encouraged to increase girls’ participation in class by selecting activities that are fun, accessible, and non-competitive. Rather than reviewing the rules, practising the skills, and eventually playing the game, Be Fit classes begin with the basic aspects of an activity, e.g. hitting a volleyball back and forth over the net, and skills and rules are introduced to the class as the girls become more skilled and comfortable with the activity. Teachers are encouraged to give frequent positive feedback to the girls and facilitate a supportive class environment. Rather than skill mastery, the focus of Be Fit is to engage girls in moderate to vigorous physical activity throughout the class period. The New Moves approach to physical activity encourages exposure to a variety of lifetime activities that are enjoyable and affirming to young women. Be Fit follows a weekly schedule that repeats throughout the class rather than the traditional use of units. Games, strength training, circuit training, and various dance and fitness modalities are included in Be Fit classes. Activities such as walking, aerobics, and dance are accessible to girls of various body shapes and sizes as well as fitness and skill level, and are used frequently in Be Fit classes. An important part of Be Fit is the use of guest instructors from the community who come to class and lead an activity including fitness, dance, and martial arts professionals. There are a wide variety of physical activities that many girls enjoy trying such as middle-eastern dance, fitness hula hooping, hip-hop dance, yoga, and self-defence. Guest instructors are chosen based on the activity they teach and their ability to be a role model for inactive girls. Instructors are selected to provide examples of a range of fit bodies, including larger instructors who are able to model that physical activity is possible for various shapes and sizes. Additionally, guest instructors

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Striving to prevent obesity and other weight-related problems in adolescent girls: The New Moves approach

provide exposure to activities that are available in the community, such as aerobics classes at a local gym or a dance class at a studio. Be Fit provides high school girls an opportunity to build skill and confidence for physical activity in a positive environment. These goals are further supported by the other components of the class, including several Be Fab sessions where girls are encouraged to set goals for physical activity and the individual counseling sessions. Be Fit also builds on the supportive environment that is encouraged in the classroom through community standards for behaviour and has a no tolerance policy for teasing about weight or appearance. Girls are encouraged to support and encourage one another to be physically active, both in and outside of the class. The various elements of the New Moves approach all aim to increase physical activity in inactive girls.

A non-dieting approach to healthful eating: Be Fueled The New Moves nutrition component aims to help girls integrate healthy eating into their daily lives. A couple of unique aspects of the New Moves Be Fueled nutrition component are the antidieting stance and the emphasis on intuitive eating. The messages provide simple concepts, e.g. 1) dieting is not effective in losing or maintaining weight; and 2) listening to one’s body may be a more effective means of managing one’s weight. Instead of encouraging dieting and being overly restrictive, Be Fueled focuses on healthy, sustainable behaviour changes that promote a healthy relationship with food. Teaching the concept of energy balance and listening to internal hunger and fullness cues allows for discussion around healthy eating without much emphasis on calories, and more specifically avoiding calorie counting and restriction as a way to lose or maintain weight. Be Fueled lessons focus on the New Moves goals of: 1) eating more fruits and vegetables; 2) eating breakfast everyday; 3) drinking more water; 4) avoiding unhealthy weight control behaviours, and 5) paying attention to portion sizes and your body’s signs of hunger and fullness. Messages provided in each lesson are more about finding balance between eating and physical activity and less about restricting food intake, and apply to all teenagers, not just those who are overweight. (p.274) Discussions often focus not only on how to make healthy choices in different situations (e.g. at the mall food court), but also talking about the fact that healthy eating means enjoying your food. The ultimate goal is for participants to realize that they can trust their bodies to tell them what they need to be healthy, and that they have a choice in how they fuel their bodies. The concepts of avoiding dieting and listening to one’s body are key components of the Be Fueled lessons. The first lesson reviews the diet cycle, which shows participants what often happens when people go on diets, i.e. restrict, feel overly hungry, give in to cravings, and feel guilty, and how this is likely to be counter-productive in terms of weight loss, weight maintenance, and overall health. In addition to discouraging dieting and meal skipping, New Moves encourages girls to listen to their bodies, including cues of hunger and fullness. To accomplish this goal the hunger/fullness scale is used (Fig. 24.3) (modified from Kratina et al., 2003). Identifying hunger and fullness cues is often a new concept for many of the girls; however, girls reacted positively to this concept and discussed strategies for paying attention to these cues. Binge eating has been reported by overweight adolescent girls (Berkowitz et al., 1993; Johnson et al., 2002), and the use of the hunger and fullness scale is one tool to help girls

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Striving to prevent obesity and other weight-related problems in adolescent girls: The New Moves approach

work on decreasing binge eating episodes. Additionally, the hunger and fullness scale provides a tool that may help girls make changes in eating behaviours without being told ‘don’t eat that’ or ‘you don’t need it’, which New Moves girls were likely to hear. Be Fueled stays away from a highly prescriptive model of telling girls what to eat, but does encourage healthy eating habits (i.e., increasing fruits and vegetables, eating breakfast, healthy snacking, etc.). Although it is important for girls to learn to understand their body and know when they are hungry and full, it is also important for them to be aware of the best ways to fuel their body. Thus, girls learn how to listen to internal signs of hunger and satiety, and receive the healthy eating/energy balance message in order to prevent both obesity and disordered eating. (p.275) No matter where a teenager falls on the disordered eating spectrum, the New Moves nutrition messages have the potential to help in forming a healthy relationship with food.

Helping girls feel good about themselves and their bodies: Be Fab The social support component of New Moves, Be Fab, focuses on increasing selfesteem, improving body image, and creating internal and external support for healthy choices. Topics covered include stress management, goal setting, media literacy, and body image. Increasing physical activity is also incorporated into Be Fab through activities with pedometers and time

Fig. 24.3 A scale used to help identify internal cues of hunger and fullness. © New Moves (2007). Based on version in Kratina et al. (2003).

management. Be Fab lessons are designed to create a positive environment for girls to discuss barriers and challenges in making healthy choices and feeling good about themselves. Adolescent girls are bombarded by media messages that infer that thin and flawless is the definition of beautiful. Therefore, one of the Be Fab lessons aims to educate girls about media messages and the narrow standards of beauty they are exposed to on a constant basis. Girls discuss common manipulations used in advertising and magazines such as airbrushing, computer editing, and lighting and make-up tricks, and are encouraged to critically examine the way media defines beauty. The lesson also focuses on girls’ collective power as consumers and discusses how they are in control of what forms of media they choose to view. An important part of this lesson is empowering girls to see that they can, and do, have a say in how beauty is portrayed in the media. In a separate lesson, girls also learn about the concept of beauty as discussed in the poem ‘Phenomenal Woman’ by Maya Angelou (Angelou, 1978). Girls are encouraged to think of the importance of inner beauty and the role self-confidence plays in feeling beautiful. When asked for examples of beautiful women in their own lives, many girls mention mothers, aunts,

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Striving to prevent obesity and other weight-related problems in adolescent girls: The New Moves approach

grandmas, and sisters and rarely mention physical characteristics as reasons why they think these women are beautiful. This discussion helps girls realize that beauty comes in various forms and that being beautiful is about more than just outside appearances. For many girls, it is not just the media that can impact their perceptions about their bodies, but also how they feel in comparison to their peers. Another Be Fab lesson spends time talking about the energy and time that goes into comparing oneself to others around them. Most girls relate well to the idea of the comparison trap, i.e., ‘I wish I had her arms’, and can come up with at least one example of this in their own life. The lesson brings up the negative consequences of constantly comparing parts of their bodies to others and girls brainstorm ideas of how to break the cycle of the comparison trap both within themselves and amongst their friends. Instead of girls focusing on the things they don’t like about themselves, New Moves encourages girls to focus on what they do like about themselves. For some girls, thinking about themselves in a positive manner is a challenge and may feel uncomfortable at first. To help girls begin to see the positive qualities they possess, this particular lesson ends with an activity in which classmates write compliments to each other. These compliments are meant to go beyond the superficial and help girls focus on the positive attributes each girl brings to the class. This lesson is a favourite among girls, and they enjoy not only receiving compliments but giving heartfelt compliments to their friends as well. Be Fab helps create a positive environment where girls feel safe sharing their insecurities and struggles around healthy choices and positive body image. Combined with the other sections of New Moves, Be Fab lessons can provide a framework and opportunities to practise real-life skills for increasing self-esteem, body image, and encouraging healthy behaviours for life.

Conclusions In developing obesity prevention programmes, it is crucial to take the contextual factors of the target population into account. For adolescent girls, obesity prevention programmes need to (p. 276) address the high social pressures on girls to be thin, the high prevalence of body dissatisfaction, and the use of unhealthy weight control behaviours among girls, particularly overweight girls (Neumark-Sztainer et al., 2002). Additional factors that need to be addressed include the socioeconomic status of participants, racial and ethnic backgrounds, and familial dynamics and support. New Moves was designed to address the needs of adolescent girls who face strong social pressures to be thin and come from diverse socioeconomic and racial backgrounds. The New Moves model is only one approach to addressing a broad spectrum of weight-related problems. Initial findings suggest that the girls truly enjoyed the programme and greatly appreciated its approach. Future analyses will indicate to what level the programme was successful in helping the girls change their attitudes, behaviours, and weight-related outcomes. Future work is also needed to explore how best to integrate programmes such as New Moves into school settings on an ongoing basis. Finally, work is needed in developing approaches for other populations such as adolescent boys, children, and adults, which take into account a broad spectrum of weight-related problems. References Bibliography references:

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Allison, K.R., Dwyer, J.J.M., & Makin, S. (1999) Self-efficacy and participation in vigorous physical activity by high school students. Health Education and Behavior 26, 12–24. Angelou, M. (1978) Phenomenal woman. And still I rise, Random House. Bandura, A. (1986) Social foundations of thought and action: A social cognitive theory, Englewood Cliffs, NJ, Prentice-Hall, Inc. Baranowski, T., Perry, C.L., & Parcel, G.S. (2002) How individuals, environments, and health behavior interact: Social Cognitive Theory. In K. Glanz, et al. (Ed.) Health behavior and health education: theory research and practice. 3rd edition. San Francisco, CA: Jossey-Bass. Berkowitz, R., Stunkard, A.J., & Stallings, V.A. (1993) Binge-eating disorder in obese adolescent girls. Annals of the New York Academy of Sciences 699, 200–206. Caspersen, C.J., Pereira, M.A., & Curran, K.M. (2000) Changes in physical activity patterns in the United States, by sex and cross-sectional age. Medicine and Science in Sports and Exercise 32, 1601–1609. Daniels, S.R. (2006) The consequences of childhood overweight and obesity. Future of Children 16, 47–67. Flattum, C., Friend, S., Neumark-Sztainer, D., & Story, M. (2009) Motivational interviewing as a component of a school-based obesity prevention program for adolescent girls. Journal of the American Dietetic Association 109, 91–94. Johnson, W.G., Rohan, K.J., & Kirk, A.A. (2002) Prevalence and correlates of binge eating in white and African American adolescents. Eating Behaviors 3, 179–189. Kimm, S., Glynn, N., Kriska, A., et al. (2000) Longitudinal changes in physical activity in a biracial cohort during adolescence. Medicine and Science in Sports and Exercise 32, 1445–1454. Kratina, K., King, N., & Hayes, D. (2003) Moving away from diets: healing eating problems and exercise resistance, Helm Publishing & Seminars. Neumark-Sztainer, D. (2005) “I’m, Like, SO FAT!” Helping your teen make healthy choices about eating and exercise in a weight-obsessed world. New York, The Guilford Press. Neumark-Sztainer, D., Story, M., Hannan, P.J., & Rex, J. (2003) New Moves: a school-based obesity prevention program for adolescent girls. Preventive Medicine 37, 41–51. Neumark-Sztainer, D., Story, M., Hannan, P.J., Perry, C.L., & Irving, L.M. (2002) Weight-related concerns and behaviors among overweight and non-overweight adolescents: implications for preventing weight-related disorders. Archives of Pediatrics and Adolescent Medicine 156, 171– 178.

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Neumark-Sztainer, D., Paxton, S.J., Hannan, P.J., Haines, J., & Story, M. (2006a) Does body satisfaction matter? Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males. Journal of Adolescent Health 39, 244–251. Neumark-Sztainer, D., Wall, M., Guo, J., Story, M., Haines, J., & Eisenberg, M. (2006b) Obesity, disordered eating, and eating disorders in a longitudinal study of adolescents: how do dieters fare five years later? Journal of the American Dietetic Association 106, 559–568. Neumark-Sztainer, D., Wall, M., Haines, J., Story, M., Sherwood, N.E., & van den Berg, P. (2007) Shared risk and protective factors for overweight and disordered eating in adolescents. American Journal of Preventive Medicine 33, 359–369. Neumark-Sztainer, D., Flattum, C.F., Story, M., Feldman, S., & Petrich, C.A. (2008) Dietary approaches to healthy weight management for adolescents: the New Moves model. Adolescent Medicine: State of the Art Reviews 19, 421–430. Ogden, C.L., Carroll, M.D., Curtin, L.R., McDowell, M.A., Tabak, C.J., & Flegal, K.M. (2006) Prevalence of overweight and obesity in the United States, 1999–2004. JAMA: the Journal of the American Medical Association 295, 1549–1555. Puhl, R.M. & Latner, J.D. (2007) Stigma, obesity, and the health of the nation's children. Psychological Bulletin 133, 557–580. Resnicow, K., Davis, R., & Rollnick, S. (2006) Motivational interviewing for pediatric obesity: conceptual issues and evidence review. Journal of the American Dietetic Association 106, 2024– 2033. Rollnick, S.R. & Miller, W.R. (1995) What is motivational interviewing? Behavioural and Cognitive Psychotherapy 23, 325–334. Sallis, J.F., Alcaraz, J., McKenzie, T.L., & Hovell, M. (1999) Predictors of change in children's physical activity over 20 months. American Journal of Preventive Medicine 16, 222–229. Stice, E. (2001) A prospective test of the dual-pathway model of bulimic pathology: mediating effects of dieting and negative affect. Journal of Abnormal Psychology 110, 124–135. Stice, E. (2002) Risk and maintenance factors for eating pathology: a meta-analytic review. Psychological Bulletin 128, 825–848. The McKnight Investigators (2003) Risk factors for the onset of eating disorders in adolescent girls: results of the McKnight longitudinal risk factor study. American Journal of Psychiatry 160, 248–254. Trost, S.G., Pate, R.R., Sallis, J.F., et al. (2002) Age and gender differences in objectively measured physical activity in youth. Medicine and Science in Sports and Exercise 34, 350–355. U.S. Department of Health and Human Services PHS (2000) Healthy People 2010 objectives for improving health, Washington, DC, U.S. Government Printing Office.

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van den Berg, P. & Neumark-Sztainer, D. (2007) Fat ’n happy 5 years later: is it bad for overweight girls to like their bodies? Journal of Adolescent Health 41, 415–417.

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Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010 Jennifer A. O’Dea

DOI:10.1093/acprof:oso/9780199572915.003.0025

Abstract and Keywords This chapter outlines the Whole School Approach and how it may be implemented in schools for preventing childhood obesity. The Framework encompasses three major areas of intervention in the school and community: 1) school curriculum, teaching, and learning; 2) school ethos, environment, and organization; and 3) school-community partnerships and services. It presents strategies for implementing the framework for obesity prevention with a ‘First, do no harm’ proviso, followed by a summary of government sponsored obesity prevention intervention programs in schools between 2000 and 2010.

Keywords: Whole School Apprach, obesity, children, intervention, eating disorders, prevention, education, schools, government, health promotion

Chapter summary This chapter outlines the Whole School Approach and how it may be implemented in schools for preventing childhood obesity. The framework encompasses three major areas of intervention in the school and community: 1) School curriculum, teaching, and learning; 2) School ethos, environment, and organization; and 3) School-community partnerships and services. Suggested strategies for implementing the framework for obesity prevention with a ‘First, do no harm’ proviso are outlined. A summary of government sponsored obesity prevention intervention programmes in schools between 2000 and 2010 is presented.

Introduction Governments have been increasingly perceived as having the major responsibility for childhood obesity prevention and much of the pressure placed on governments has been in the area of

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providing resources for school health promotion. An important proviso in the implementation of any school-based initiative is that the programme is considered safe and effective as well as feasible in an already crowded school curriculum. As outlined in previous chapters school-based programmes to prevent overweight and obesity may unintentionally create harmful effects if students perceive the initiatives as stigmatizing and if teachers and school staff transfer negative beliefs and attitudes to students including poor body image; prejudices about body weight; and bias towards students, as in prejudice towards overweight students. In addition, as reported by Yager in Chapter 5 (page 56) teachers may be poor role models for students if they are obsessed about having the ‘perfect’ body themselves or if they believe that fitness and health can only be achieved at a slim body weight. Those implementing school-based programmes should examine potentially harmful outcomes before beginning school activities. As several authors suggest in this book (Neumark-Sztainer, Maclean, Jess Haines, and others) the prevention of obesity should be undertaken with great care, and with the overall intention of providing a supportive and broadly ‘healthy’ environment for children, which takes into account their physical, social, emotional, cultural, and spiritual health. Prevention of obesity together with prevention of eating disorders, bullying, and body image concerns is a suitable and sensible approach. Suggestions for effective and safe schoolbased preventive strategies aimed at childhood obesity prevention may therefore prove most effective when coordinated and encompassed within a ‘whole school’ or a Health Promoting Schools Framework. (p.279) The World Health Organization (WHO) Health Promoting Schools Framework (WHO, 1998; Nutbeam, 1992) outlines a holistic approach to foster health within a school and its local community by engaging health and education officials, teachers, students, parents, and community leaders in making common efforts to promote health. A ‘whole school’ or health promoting school approach has an organized set of policies, procedures, activities, and structures designed to protect and promote the health and well-being of students, staff, and wider school community members. The Health Promoting Schools concept is based on the premise that education and health are inseparable and that health supports successful learning, and successful learning supports health. The ideology of the Health Promoting Schools Framework states that the whole school and its surrounding community must implement policies, practices, and other measures that respect individual self-esteem, provide multiple opportunities for success, and acknowledge good efforts and intentions as well as personal achievements. A Health Promoting School also strives to improve the health of school personnel, families, and community members as well as students, and it works with community leaders to help them understand how the community is influential in affecting health and education. Table 25.1 contains the WHO guiding principles for developing health promoting schools. Important features include the holistic nature of health, gender equity, involvement and ownership of the whole school community, participatory decision-making, sustainability, cultural appropriateness, and inclusion of measures to increase health literacy. WHO defines health literacy as the cognitive and social skills that determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain health

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Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

(WHO, 1998). Thus, the Health Promoting School promotes empowerment of students, teachers, parents, school staff, and community members because they learn to obtain and use health information. Table 25.1 Guiding principles for future development of health promoting schools ◆ Good health supports lifelong learning, living, and well-being. ◆ Students grow and learn in a safe, caring, responsive, and empowering environment. ◆ Health promoting schools view health holistically, addressing the physical, social, mental, intellectual, and spiritual dimensions of health through comprehensive programmes. ◆ Equal access by male and female students from all population groups to educational opportunities is essential for promoting quality of life. ◆ Health promoting schools ensure a coordinated, comprehensive approach to health and learning by linking curriculum with the school ethos/environment and the community. ◆ Health promoting schools are inclusive – the whole community of students, parents, staff, and local agencies are engaged in school activities. ◆ Active participation is based on respecting skills, values, and experiences of parents, students, and staff. ◆ Collaborative, participatory decision-making and personal action provide the conditions for the empowerment of individuals and the school community. ◆ Staff and parent well-being is an integral part of health promoting school activity. ◆ Partnerships result in action, which is more effective, efficient, and sustainable. ◆ Addressing health literacy is an important component of a health promoting school. ◆ The contribution of diverse cultures and groups is supported and valued. Table 25.1 reproduced with permission from the Australian Health Promoting Schools Association. http://www.edfac.usyd.edu.au/projects/ahpsa/ (p.280) The framework focuses on three areas of intervention within the school and its local community: 1) School curriculum, teaching, and learning; 2) School ethos, environment, and organization; 3) School-community partnerships and services.

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Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

School curriculum, teaching, and learning The Health Promoting Schools Framework outlines requirements for a planned and sequential health education curriculum across all age groups and the need for inter-sectoral and crosscurricula approaches. An example of this concept includes focusing on dieting prevention in Health Education classes (skill development to reduce the influence of peer group pressure), English classes (the impact of persuasive advertising), and Science (normal composition of the human body). The cross-curricular approach ensures health messages remain consistent across subject areas. In addition, the framework emphasizes teacher training in specific areas and the opportunity for teachers to reflect on their own values, beliefs, prejudices, and life experiences to be effective role models. In terms of preventing body image problems and obesity, teachers and other school and community personnel may require training to better understand these problems, training in effective and safe preventive strategies, and access to counseling and referral services.

School ethos, environment, and organization This section of the framework includes beliefs, attitudes, and norms within the school and local community that form the overall ‘ethos’ of the school environment. The area includes school structures, policies, and practices that contribute to a healthful environment. To foster a healthful school environment, health promotion policies of the school must be examined. For example, the school may need to examine its school meal policy (for-profit or not-for-profit basis) and may need to introduce policies about teasing, bullying, dress codes, prejudice, and the need for special programmes such as school sports programmes specifically suited to the needs and preferences of girls or overweight students.

School–community partnerships and services Part of the Health Promoting Schools holistic approach involves developing collaborative relationships with students’ families, school and community health workers, youth and educational services, and nongovernment agencies. Resources in school and the community can complement healthy attitudes and activities promoted in school to be reinforced in the community. In regard to preventing obesity, examples of exchanging resources between school and community include providing access to gyms, sporting fields, private exercise facilities, access to health services for students, teachers, school nurses, and families. Complementary educational activities such as training programmes for preventing eating and body image problems for parents, school nurses, youth workers, coaches, dance teachers, journalists, and health workers may be designed to maximize the impact of school-based curricula. A comprehensive collaborative approach between the school and community will enable implementation of policies, procedures, activities, and structures required to promote both a healthy body image and healthy eating and exercising behaviours in children, teachers, parents, and community members. Ecological and environmental considerations Development of healthy lifestyles should encompass positive, enjoyable activities, which promote the prevention of obesity as well as the prevention of potential eating problems and the (p.281) Table 25.2 National and state initiatives relevant to child and adolescent obesity prevention in Australian Government Schools – 2000–2010

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Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Healthy school canteen & nutrition related initiatives

Eat Well Australia: 2000– 2010 Policy aimed at improving the nutritional health of Australians Coordinated by the Strategic InterGovernmental Nutrition Alliance (SIGNAL) Built on existing public health strategies such as ‘Acting on Australia’s Weight’, ‘Active Australia’, the National Breastfeeding Strategy, and the National Action Plan on Vegetables and Fruit. Introduced guidelines for Healthy School Canteens, and the Traffic light (Red, Amber, Green) food classification system

Seeks to increase First priorities include: the number of ◆ review research on food advertising and th children who fall Television Advertising Code for Children and within the healthy changes to the code, compliance monitoring weight range by practices promoting good ◆ review food supply strategies for school ca eating habits and identify any appropriate support physical activity. It also aims to ◆ develop best practices in preventing eating increase the support demonstration initiatives and availability of healthy meals ◆ assess funding options targeting children a and snacks for children in http://www.health.gov.au/internet/main/publish schools. health-pubhlth-strateg-food-nphp.htm The strategy focuses on: ◆ increasing the consumption of vegetables and fruit ◆ reducing overweight and obesity ◆ promoting good nutrition for women and children ◆ promoting good nutrition for vulnerable and disadvantaged groups

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Actions

Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Sport/PE related initiatives

Healthy Active Australia Community and Schools Grants Programme provided funding for: ◆ direct service provision and/or equipment for direct service provision, e.g. physical activity equipment

Focus

Support communities to help promote physical activity and healthy eating at the local level. Aims to raise awareness among Australians of the importance of ◆ community/school healthy living and education, training, maintaining a and information healthy body dissemination weight. It will target all ◆ whole of community Australians, with projects a particular focus on youth. Healthy Active Ambassadors Programme: ◆ initiative of the Australian Government, funded under the Australian Better Health Initiative Particular focus on youth

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Actions

Provided grants between $10,000 and $200,000 to 18 months, to not-for-profit organisations to u eating and physical activity initiatives at the loc the Australian Better Health Initiative (ABHI). The first round of grants was announced in Octo the second round in August, 2008; therefore pro million in funds in total, the majority of which w Announced in July 2006 and ran for 2 years as a Australian Better Health Initiative, a joint Austr territory government initiative. ‘Ambassadors’ – celebrities and sports people w healthy lives were appointed to promote the ben life choices to the community. http://www.healthyactive.gov.au/

Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

Active Australia Designed to provide a national participation framework for all sport, recreation, and physical activity Collaborative venture: Department of Health and Family Services, the Australian Sports Commission, State and local governments, and the sport and recreation industry The Strategic InterGovernmental forum on Physical Activity and Health (SIGPAH) is parallel to SIGNAL, but addresses physical activity

Aims to improve the health and well-being of all Australians by promoting increased levels of moderate intensity physical activity ◆ Increase lifelong participation in physical activity

Main strategies included education, environmen and monitoring Incorporates Get Moving Initiative http://www.healthyactive.gov.au/

Schools Assistance Act 2005–2008 Australian government funding for physical activity programmes for schools when schools meet the policies’ objectives

A minimum level of physical activity in schools for the compulsory years of schooling

◆ Realize the social, health, and economic benefits of participation ◆ Develop quality infrastructure, opportunities, and services to support participation

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Schools Assistance Act 2005–2008 stated that a schools are to provide 2 hours of physical activi effective 01/01/05 in order to be eligible for fed The policy does not outline when and how such undertaken, but states that it should be within s Provided $1,500 Healthy School Communities g healthy eating activities. http://www.dest.gov.au/sectors/school_educatio programmes_funding/forms_guidelines/quadgui schools_quadrennial_administrative_guidelines_

Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

Other obesity prevention related initiatives

Active Australia Schools Network National network of schools that value sport and physical activity ACHPER National manages and coordinates the network on behalf of the Australian Sports Commission, and provides funding for the network.

Communicate that physical activity is something that is fun, enjoyable, and rewarding, whether it is done on your own or with others. ◆ Increase awareness of the benefits of regular, moderate physical activity

Advice and ongoing support to schools from nat local organizations. Opportunity and advice to develop a school plan physical activity. Access to information on schoo and initiatives, teaching ideas, available resourc articles, useful contacts, and special member of provision of support materials, resources, and in to raise the profile of sport and physical activity community. http://www.sportandrecreation.nt.gov.au/sportd schools_network

◆ Maintain motivation (avoid alienation) amongst people who are already sufficiently active and amongst people who may participate in vigorous activity through organized forms of sport and recreation

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National Initiatives

Description

Focus

Actions

◆ Increase awareness of the ‘30 minutes, moderate intensity, accumulated’ message through an emotional appeal to the target audience and through appropriate portrayal of incidental physical activity Crunch’n’sip Schools are encouraged to have formal breaks to eat fruit and vegetables and drink water in the class room

Assist physical and mental performance and concentration in the classroom through nutritious eating and regular drinking

Healthy Weight 2008 Goals: National Action Agenda ◆ Achieve for children and young healthier people and their families weight in children and young people ◆ Increase the proportion of children and young people who participate in and maintain healthy eating and adequate physical activity

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‘Crunch & Sip’ is a set break to eat fruit (or sala drink water in the classroom. Encourages and provides nutrition activities tha incorporated within the school curriculum. http://www.crunchandsip.com.au/default.aspx

Focus action on giving children, young people, a best possible chance to maintain healthy weight everyday contacts and settings. http://www.health.gov.au/internet/healthyactive Content/healthy_weight08.pdf/$File/healthy_we

Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

Goals: ◆ Strengthen children, young people, families, and communities with the knowledge, skills, responsibility, and resources to achieve optimal weight through healthy eating and active living ◆ Address the broader social and environmental determinants of poor nutrition and sedentary lifestyles Active After Schools Programme Provides Australian primary school-aged children with access to free, structured physical activity programmes in the after-school timeslot Introduced in 2005, will run until 2009 In association with Heart Foundation's after-school care programme

Aims to deliver a quality, safe, and fun after-school physical activity programme for primary schoolaged children Designed to engage traditionally inactive children in structured physical activities and build links with communitybased organizations to create opportunities for ongoing participation

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The government will spend $90 million over 4 y an after-school physical activity programme Provide Australian families with a convenient an opportunity to support the healthy development school-aged children (5 to 12 years). http://www.health.gov.au/internet/healthyactive Content/initiatives-a

Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

Queensland Smart Choices – healthy (QLD) food and drink supply strategy for Queensland schools Offers suggestions and policies that provide schools with the necessary knowledge to provide nutritious and healthy food and drink to students

Aims to offers healthy food and drink choices to students in Queensland schools ◆ School food and drink supply includes all situations where food is supplied in the school environment – tuckshops, vending machines, school excursions, school camps, school events such as celebrations and sports days, and food used in curriculum activities

Uses the food and drink spectrum GREEN ‘Hav ‘Selected Carefully’, and RED should be sold on occasions per term. Policies sent to all Queensland schools in July 2 During 2006, schools began making the necessa Implementation mandatory in all state schools 0 Non-government schools are encouraged to ado within their school community. http://education.qld.gov.au/schools/healthy/food strategy.html

New South Wales (NSW)

Aims to move beyond nutrition guidelines for school canteens to a governmentendorsed approach that helps schools determine the healthier types of foods that should be available for sale in their canteens

Traffic light categorization: RED 'Occasional' – Do not sell these foods on m occasions per term AMBER 'Select carefully' – Do not let these food menu and avoid large serving sizes GREEN 'Fill the Menu' – Encourage and promot the canteen Transition throughout 2004; Mandatory end ter A number of resources have been developed to meet the requirements of the strategy including Menu Planning Guide and The Fresh Tastes Too http://www.health.nsw.gov.au/publichealth/heal obesity/canteens.asp

Fresh Tastes NSW Healthy School Canteen Strategy Policy sets out requirements associated with a governmentendorsed approach that assists schools to determine nutritional and healthier types of foods for sale in their canteens Requires all NSW government schools to provide a healthy, nutritious canteen menu in line with the Australian Dietary Guidelines for Children and Adolescents Traffic light categorization

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Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

Nutrition Ready-to-Go at Out of School Hours Care (OOSHC) A project to promote good nutrition and physical activity for children Strategies included: ◆ Review and development of menus and food and nutrition policies for OOSH services

To increase the number of OOSH services that provide nutritionally balanced food and drink, that have nutrition and food safety policies, and that use food safety practices ◆ Improve nutrition, physical activity, and food safety

Provides background information on nutrition fo understanding of the need to serve healthy food obesity epidemic, practical information on menu menus, label reading, catering for special diets, nutrition and food safety policies; over 35 recip trialed in the OOSH setting and ideas for creati eating environment and conducting fun food act children. The project also includes statewide accredited n safety training for OOSH staff and for OOSH se http://www.healthykids.nsw.gov.au/topics/2155.

◆ Resource development ◆ Staff training ◆ Feedback on menu planning and policy development to services ◆ Small grants were also available to assist services in disadvantaged communities

◆ Providing access to healthy food choices in an environment that promotes healthy eating

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Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

Victoria (VIC)

Go for Your Life Healthy Canteen Policy Provides information and practical ideas on providing healthy foods in schools for all Victorian primary schools ◆ Voluntary

Promote healthy eating and increase levels of physical activity Support students making healthy food choices at school and in life This includes promoting opportunities for: ◆ to the community, such as through volunteering Increasing levels of physical activity

Explain the guiding principles, including food se categories, food, safety, and the role of the scho developing a school food service policy. Assist schools and canteens to make appropriat choices. Provides learning activities for each of the six le Victorian Essential Learning Standards (VELS) 10. Provides information for primary schools who d site canteen, but provide alternative forms of fo http://www.healthykids.nsw.gov.au/topics/2155.

◆ Traffic light system Soft drinks to be phased out over 2007, banned 2008 Part of Victorian Initiative ‘Go for Your Life – 2006–2010

◆ Improving eating habits ◆ Getting involved with neighbourhood and local community activities ◆ Making worthwhile contributions

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Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

Tasmania (TAS)

Canteens Accreditation Programme (CAP; voluntary) Works in partnership with government health and education agencies, local government, parent bodies, and the food industry to facilitate and promote the provision of a healthy and nutritious food services in Tasmanian school canteens Follows RED, AMBER, GREEN food categorization to help reduce nutritional problems by offering and promoting a good selection of nutritious, tasty, and attractive foods and supporting classroom nutrition education

Make it possible for children to buy nutritious and healthy food at competitive prices during the school day Make it easier for children to remain within the school grounds during lunch time for their own safety. Provide experiences of a variety of foods and dishes so that they support the skills and knowledge learnt in the classroom about food and nutrition through having the opportunity to be involved in decision-making in the school

Continue to implement the Cool Canteens Accre Programme in schools and provide resources an canteens implementing the programme. Conduct professional development for canteen s parents on linking canteen practices to the Esse curriculum and improved financial managemen Work with the food industry to develop and prom choices for school canteens. 54% of the 170 government schools are accredi towards accreditation. http://www.tascanteenassn.org.au/

Northern Territory (NT)

Healthy Canteen Guidelines Guidelines that suggest that the canteen can influence other school food settings and the nutritional message should be ‘reinforced at all other points where food is supplied in the school (e.g. excursions, sports days, vending machines)’. ◆ Developed 1997, revised 2005

Improve nutritional status and the health, and to reduce the burden of dietrelated early death, illness, and disability Aim to assist the school canteen play an important role in promoting healthy eating among children

No traffic light system, but recommends avoida foods Have been designed to assist canteen managers committees, and other interested school commu plan and provide nutritious food that complies w dietary advice. The guidelines also provide advi and safety. Includes Tummy Rumbles Guidelines for Remot provides nutrition advice for remote and rural N canteens, and is based on The Aboriginal and To Islander Guide to Healthy Eating. http://www.parentsjury.org.au/tpj_browse.asp? ContainerID=tpj_school_nutrition_guidelines

◆ Not compulsory

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Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

South Australia (SA)

Healthy Eating Guidelines Framework for schools and preschools to develop their own Healthy Eating Policy through six areas of practice: ◆ Curriculum

Western Australia (WA)

Star Choice Canteen Accreditation Programme Introduced as a voluntary programme, which awards schools operating healthy canteens by using a star rating basis of three, four, or five stars, similar to the rating standard used in other areas of hospitality and tourism Accredited school canteens are required to meet defined criteria in four key areas ◆ Canteen policy

Focus

Ensure children and students learn about, experience, and practice healthy eating Aims to support healthy environments in schools and ◆ The learning preschools, environment address global concerns about ◆ Food supply (this the levels of diet includes canteens and related chronic food services) disease, increase fruit and ◆ Food safety vegetable ◆ Food related health consumption, provide support planning recommendations ◆ Working with for healthy families, health eating, promote services, and industry healthy weight, and address food related issues for priority groups

◆ School community involvement ◆ Canteen menu

To increase the availability, promotion, and sales of foods and drinks categorized ‘GREEN’ under the Government Healthy Food and Drink Policy, which is consistent with the Australian Dietary Guidelines for Children and Adolescents and the Australian Guide to Healthy Eating, in schools in Western Australia

◆ Hygiene and food safety

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Actions

Since 2004 have had recommended/not recomm 2007 mandatory participation Regulation from 2008 – junk food banned http://www.decs.sa.gov.au/eatwellsa/pages/eatw reFlag=1

Introduced in 1998 Mandatory from 2007 Recognized and rewarded those schools operati profitable canteens and also provided incentive towards star status Fate Offers training courses (3 hours) ◆ Developed to assist schools meet the stand

◆ Completion of the training course is a preparticipation irrespective of any other trainin have been undertaken by the canteen manag

http://www.waschoolcanteens.org.au/pages/star starcap.htm

Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Queensland Healthy SchoolsInitiative (QLD) Compulsory sport and PE curriculum time: ◆ Adheres to federal guidelines ◆ Years 1–10 = 2 hours p/week

Focus

Actions

Aims to enhance the physical activity component of the school's health and well-being curriculum programme

Schools implement a programme that reflects th community's needs and opportunities. Each school sport district is encouraged to deve suitable to the district size, remoteness of mem resources, and historical experience. http://education.qld.gov.au/schools/healthy/

Aims to increase student participation in physical activity and to improve the quality of that activity

Requires schools to plan for implementation of PE (primary) or 2 hours per week of sport and p (secondary schools) commenced in July 2008, w implementation in place by December 2008 Increase the curriculum time in which students engaged in physical activity and improve the qu activity

◆ (From 01/01/2005) In addition, schools with greater than 300 students are required to participate in interschool sport. Smart Moves – Physical Activity Programme Structured exercise curriculum, which addresses nationwide concerns about the lack of physical activity among today's youth. Key strategy in the Toward Q2: Tomorrow's Queensland 2020 healthy children target to reduce obesity by onethird

http://education.qld.gov.au/schools/healthy/phys programs.html Be Active Queensland (2006–2010) Framework for coordinated action to increase physical activity, by the health sector Developed through the Queensland Public Health Forum, an alliance of 18 government and nongovernment organizations

Aims to increase the amount of physical activity among Queenslanders, particularly inactive or mostly sedentary individuals ◆ Develop infrastructure that supports active living initiatives ◆ Promote a whole-of community approach to active living

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Covers requirements relating to student particip and welfare of students, equipment, venues and conditions and procedures for a range of sports activities Offers resources to help support communities a building infrastructure, policies, and sporting ve http://www.health.qld.gov.au/qphf/documents/3

Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

New South Wales (NSW)

School Sport Policy Informs and supports school communities in the planning and implementation of safe sport, outdoor recreation, and physical activity conducted in NSW government schools Compulsory PE/sport ◆ 60 min/week primary

Aims to set out standards and requirements for the planning, safe implementation, and management of specific sports and outdoor recreation activities including advice on the supervision and welfare of students engaged in sport and physical activity Encourage participation in sport and physical activity

Policy has been in place since 1992 Covers requirements relating to student particip and welfare of students, equipment, venues and conditions and procedures for a range of sports activities https://www.det.nsw.edu.au/policies/student_se student_welfare/safe_sport/PD20020012.shtml

Provide an opportunity to promote physical activity in children

Provide asessment and feedback on after-schoo physical activity facilities and programmes, and to meet the quality practice guidelines; e.g. dev movement, coordination, balance, and strength The programme will also provide ideas for suita activities to promote physical activity, training o appropriate games, and suitable resources

◆ 80–120 min/week secondary

Physical activity project at Out of School Hours Care (OOSHC ) The policy strives to improve children's opportunities for and participation in physical activity at out-of-school hours (OOSH) care by implementing programmes, providing resources and training staff. Physical activity project will be undertaken with coordinators involved in the NRG @ OOSH nutrition strategies http:// www.health.gov.au/ internet/healthyactive/ Publishing.nsf/Content/ initiatives-a

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Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

Following the needs assessment, strategies will OOSH centres will be able to choose strategies assist them to improve physical activity opportu centre. Strategies will focus on factors that imp activity behaviour in children at individual, soci environmental levels. Improvements were seen in the proportion of m vigorous activities programmed each week. Chi participation showed a significant shift from low intensity activities. Improvements were also see of services with planned physical activity progra physical activity policies. Australian Capital Territory (ACT)

Physical Education and Sport Provides advice to schools on PE and sport matters, disseminates information, facilitates professional learning programmes, and provides administrative support to the primary (PSSA) and secondary (SSSA) schools’ sports associations.

Encourages schools to place a high priority on sport and physical activity 1 Development of a sports policy by every school

In line with the ACT curriculum framework (P–1 accredited ACT Board of Senior Secondary Stud 12) course. Compulsory Sport and PE ◆ 7–10 – Compulsory to have 180 minutes of be active ◆ 3–6 – Same as 7-10

◆ K–2 – 25–30 min per day 2 Allocation of http://www.det.act.gov.au/teaching_and_learnin sufficient time curriculum_programs/pe_and_sport 3 Allocation of adequate resources 4 Adequate teacher training

Develop appropriate administrative structures, which ensure viable physical education programmes Victoria (VIC)

School Sport Policy Informs and supports schools in the implementation of safe sport, outdoor recreation, and physical activity conducted in Victorian Government schools

Provide quality sporting opportunities to promote physical and social development for all government students in Victoria

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Compulsory sport/PE ◆ Years P–3: 20–30 min p/day.

◆ Years 4–6: 3 hours per week; 50% must be

◆ Years 7–10: 100 minutes per week each for education and sport

Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

Policy brought in 2002 Offers practical suggestions for how councils ca and strategic priorities in a more integrated wa http://www.sport.vic.gov.au/

Tasmania (TAS)

Victorian Institute of Sport Sportsperson in Schools Programme Joint initiative between the department and the Victorian Institute of Sport. Facilitates school visits by some of Australia’s highest profile athletes, promoting the benefits of organized physical activity and healthy lifestyles for students.

Aims to promote the value of an active and healthy lifestyle by utilizing elite level athletes as role models

The programme is provided at no cost to all Vic schools Successful schools receive 2–3 visits by a nomin with each visit running for 1½–2 hours The programme is not designed to provide coac however, students may have the opportunity to activities relating to the athletes’ sport http://www.vis.org.au/spisp.asp

Get Moving Tasmania State-wide initiative that supports the development of a more physically active Tasmanian community. Coordinated as part of the Premier's Physical Activity Council (PPAC)

Aims to increase the level of physical activity of all Tasmanians and promotes active and healthy lifestyles Promote the importance of incorporating sufficient levels of physical activity on a daily basis to assist in maintaining a healthy lifestyle

Encourages at least 30 min a day for adults and children of physical activity School physical activity programmes, suggestio such as walkathons http://www.getmoving.tas.gov.au/

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Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

Move Well Eat Well Aims to: Offers: Initiative that enables ◆ Increase ◆ Recognition of achievement schools to identify active play and ◆ A whole school approach to promoting hea strengths and physical physical activity weaknesses around their activity policies and programmes ◆ A simple framework for planning and actio ◆ Decrease for promoting nutrition consumption and physical activity, ◆ Tailored Tasmanian resources for teachers of high-energy identify priority areas for health professionals foods and action, develop a plan of drinks action to improve the ◆ Clear links to the Tasmanian Health and W school environment and curriculum. ◆ Promote student health, and classroom ◆ School sport policy currently under develo involve a wide range of learning, a people from the school sustainable and community in this commitment to planning process children’s health and well-being, and partnerships with families to support a healthy school environment ◆ Provide coordination and help build partnerships between health professionals in local areas and participating schools

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◆ No compulsory school sport

◆ Schools are recommended to do 2 hours pe 01/01/2005)

A review of Award Schools is undertaken every http://www.education.tas.gov.au/movewelleatwe

Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

Northern Territory (NT)

GoNT Be Active A Physical Activity Strategy and Action Plan for the Northern Territory. Adhere to federal guidelines of 2 hours per week (from 01/01/2005)

Promote physical activity and provide encouragement to be more involved and active in regular physical activity Goal 1: Ensure coordination and collaboration of physical activity promotion within the Northern Territory

Incorporates the ‘find 30’ initiative – call to acti Territorians to put together at least 30 minutes intensity physical activity (like walking) on mos days, as recommended by the national physical for adults http://www.health.nt.gov.au/Nutrition_and_Phys goNT/index.aspx

Goal 2: Develop greater public awareness of the social, economic, environmental, and health benefits of regular physical activity along with the negative impacts of physical inactivity

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Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

Goal 3: Increase opportunities for participation through the development of programmes, policies, regulations, and infrastructure that support Territorians to reintegrate physical activity into their everyday life South Australia (SA)

Be Active (2004–2008) Framework which assists in promoting the importance and benefits of being physically active The strategy seeks to ensure efficient and effective use of resources through improved collaborative and cooperative efforts across government and the South Australian community There is no compulsory participation in school sport

To facilitate, support, and encourage lifelong involvement in physical activity by all South Australians Increase the number of South Australians regularly participating in physical activity

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Links with other initiatives that impact on physi as the State Strategic Plan and the work being c Healthy Weight Taskforce Developed and implemented programmes and s Adheres to federal guidelines of 120 minutes PE 01/01/2005) http://www.publications.health.sa.gov.au/

Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

Western Australia (WA)

Be Active WA Programme set up to strengthen the promotion and development of physical activity programmes for healthy lifestyles Incorporates initiatives including Crunch&Sip http:// www.beactive.wa.gov.au/

Aim to double the number of schools participating in SportsFun, physical activity programmes Achieve an increase in active transport to school

Compulsory School Sport years 1–10 ◆ 2 hours per week

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◆ Compulsory from 2007

Junior Sport Development Days (JSDD) program metropolitan and regional areas Develop resources, facilities, and training to im availability and participation in physical activiti Additional funding for professional developmen assist them to successfully engage primary scho quality physical activity Achieved a 16.8% reduction in car use Number of SportsFun leaders increased from 13 to 1723 in 2006/2007; 60 schools are currently Number of certified schools in WA increased fro of all WA schools are currently certified Aim to have an additional 150 schools actively w becoming a certified Crunch&Sip School

Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Queensland Active-Ate (QLD) Collection of resources developed by the Queensland Health Tropical Public Health Unit Network to promote physical activity and nutrition in primary schools. Promotes the adoption of healthy eating practices and physically active lifestyles by children. Highlights the links between health issues and student health and well-being through a skills-based approach

Focus

Actions

Developed to contribute towards improved health and wellbeing among Australian schoolchildren Designed to increase knowledge and awareness of healthy eating and physical activity among students The main focus of the classroom activities is to increase students’: ◆ Knowledge and skills in nutrition to choose healthy foods

Programmes were developed in the context of t Health And Physical Education Syllabus. Key ar programme include: units of work for each year background material, student work sheets, infor hardcopy resources for school wide programme information sheets about a range of nutrition iss other websites for teachers and students $11.1 million Safe and Healthy Schools Policy a allocated to Department of Education and the A expansion, and enhancement of the Active-Ate P http://education.qld.gov.au/schools/healthy/acti

◆ Participation in physical activity ◆ Understanding of the links between nutrition and physical activity Australian Capital Territory (ACT)

Eat Smart Play Smart Provides training for Out of School Hours Care coordinators on nutrition, physical activity, and body image

Aim of ultimately improving the nutritional quality of food and drinks provided, increase the levels of physical activity, and improve awareness of healthy body image among Out of School Hours Care programmes

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Provides training, resources, suggestions, and l School Hours Care coordinators http://www.heartfoundation.org.au/Healthy_Liv Eat_Smart_Play_Smart/Pages/default.aspx

Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

Victoria (VIC)

Go For Your Life Tries to equip Victorians with the knowledge, confidence, skills, and resources to help them make healthy and active choices that promote their lifelong health

Aims to improve the health and well-being and encourage Victorians to become more active ◆ Increase physical activity levels

Provides activities for particular population gro activities designed to create communities, struc environments that support healthier eating and physical activity. Has allowed for assessment of progress and rea directions and initiatives, $57.5 million over 4 y the state government http://www.goforyourlife.vic.gov.au/

◆ Reduce sedentary behaviour ◆ Increase active transport Stephanie Alexander Kitchen Garden Project Aims to positively influence children’s food choices in a hands-on programme, which encourages primary children to learn about growing and cooking fresh food

Develop lifelong healthier and happier eating habits Promotes healthy lifestyles through greater physical activity and nutritious eating, and addressing the rising prevalence of obesity and diabetes

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Students are required to spend one class in the involved in creating and caring for it and a class cooking with the produce they have grown. The programme provides resources, ideas, and an interactive website. Grants of $2.4 million to part-fund 40 new kitch programmes In 2007, the Australian Government agreed to s additional projects around Australia by 2012 http://www.healthyactive.gov.au/internet/health publishing.nsf/Content/kitchen-garden

Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Tasmania (TAS)

Description

Focus

Actions

Eat it!: Fruit + Veg programme Centres on the need to consume fruit and vegetables by primary school children and their families Piloted in over 50 Victorian Schools during 2003 and 2004

Increase the Provides resources, links, and support for schoo awareness of the community including: need to eat more ◆ Suggested activities for promoting healthy fruit and and community groups vegetables among ◆ Healthy eating information and ideas for sc primary schoolaged children ◆ Ideas for teachers, school canteens, and re Increase positive together in increasing the consumption of ve attitudes towards fruit and http://www.health.vic.gov.au/nutrition/child_nut vegetables among primary schoolaged children Encourage opportunities for primary schoolaged children to plan prepare, taste, and be creative with vegetables and fruit

1Seven – Move More, Eat Well Encourages children (5– 12yrs) to participate in 1 hour of moderate to vigorous physical activity and eat seven servings of fruit and vegetables per day

Aims to increase the level of physical activity of Tasmanian children and promotes active and healthy lifestyles

The programme provides web-based material, c resources, games, and giveaways and provides ambassadors and athletes from netball, AFL, an Move Well Eat Well Award offers: ◆ Support to meet key criteria which reinfor and promote physical activity

◆ Recognition of schools’ achievements

◆ A whole school approach to promoting hea physical activity

◆ A simple framework for planning and actio

◆ Tailored Tasmanian resources for teachers health professionals

◆ Clear links to the Tasmanian Health and W curriculum http://www.1seven.com.au/

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Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

National Initiatives

Description

Focus

Actions

South Australia (SA)

Eat Well be Active SA 2006–2010 Outlines ways for government and nongovernment organizations to work together to promote healthy weight for children, adults, and families It includes preventive and management strategies and identifies priority actions at a variety of levels, including policy and programme development, workforce planning, research, and monitoring

Aims to Funded for $2.6 million over 5 years (2006–201 contribute to government of South Australia healthy weight in Encompasses: children, young ◆ Teacher well-being sessions/nutritional and people (0–18 training years) and their ◆ Mentoring for canteens families through promoting ◆ Physical activity policy healthy eating and physical ◆ Nutrition policy activity Four main ◆ Improvements in drinking water facilities messages: ◆ Reinvigorating outdoor learning environme ◆ Eat fruit and veg ◆ Canteen menu improvements ◆ Drink water ◆ Programmes and resources including healt curriculum resources ◆ Support breast feeding Almost 100% of early childhood settings, primar schools have been engaged, 77% of schools hav ◆ Active play healthy eating policy, the first physical activity Day Care in SA has been developed and implem facilities in 21 early childhood settings and scho or upgraded (i.e. 43 filter taps, 7 water coolers, 3 upgrades http://www.health.sa.gov.au/pehs/branches/hea strategy-sa-06-10.pdf

(p.282) (p.283) (p.284) (p.285) (p.286) (p.287) (p.288) (p.289) (p.290) (p.291) (p. 292) (p.293) (p.294) (p.295) (p.296) (p.297) improvement of body image. These strategies should be facilitated in a coordinated approach and should not be confined to the individual or to the school classroom. A holistic environmental approach to the prevention of body image and eating problems as well as child overweight, such as the Health Promoting Schools Framework (O’Dea & Maloney, 2001), theorizes that whole communities need to be involved in fostering overall health within school and community environments. Media literacy and media advocacy interventions are also encouraged in order to encourage healthy eating, physical activity, and self-acceptance and help to reduce the internalization of the thin ideal and the pervasive body image norms for males and females, which are constantly promulgated and reinforced by the media. The impact of media literacy programmes is believed to be most powerful in an environment where the messages are positive, the whole school is supportive, and when the final result is one of rejection of body stereotypes and supportive of ways of overcoming barriers to healthy lifestyles. Hence, whole systems such as families, schools, communities, governments, and corporations need to be aware of, involved in, and committed to the protection and enhancement of child

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Whole-school and health promoting school approaches to obesity prevention— government policy directions in Australia between 2000 and 2010

health and the prevention of these pernicious body image and eating problems, which are currently burgeoning among our children and our youth.

Conclusions Research reinforces the suggestion that educators need preventive strategies which encompass objectives of whole health promotion including healthy eating, improved body image, increased physical activity as well as prevention of obesity. School-based programmes may provide an efficient and effective way to approach these problems utilizing a Health Promoting Schools Framework, which offers a suitable approach because it encompasses a range of influences – internal and external – to the school environment. The holistic focus of the Framework targets numerous aspects of promoting a healthy lifestyle including school curricula, policies, and attitudes as well as the local environment and community activities, services, and resources. Collaboration among school, home, and community, which is central to implementing the framework, enables a shared language and a shared way of working and understanding each other (WHO, 1998). This new approach provides a structure that offers the flexibility required to suit individual school needs and a diversity of problems. Implementing the Health Promoting Schools Framework for promoting a healthy lifestyle, preventing eating and body image problems, as well as obesity prevention may provide schools and local communities with a safe, effective, and long-term solution to these community problems. This chapter has provided an outline of the theoretical framework behind the health promoting schools approach and has illustrated how several Australian governments and schools have successfully implemented strategies to promote overall health within their school and community. References Bibliography references: ACT Department of Education and Training. Physical education and sport unit. Available at (accessed 10 November 2009). Australian Football League Move more eat well. Available at: (accessed 10 November 2009). Commonwealth of Australia. A healthy and active Australia. Available at: (accessed 5 November 2009). Commonwealth of Australia. Active after-school communities. Available at: (accessed 10 November 2009). Commonwealth of Australia. Healthy weight 2008. Available at: (accessed 8 November 2009). Commonwealth of Australia. National public health partnership's nutrition strategy and action plan – eat well Australia, 2000–2010. Available at: (accessed 10 November 2009).

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Commonwealth of Australia. Schools Assistance Act 2008. Available at: (accessed 10 November 2009). Commonwealth of Australia. Stephanie Alexander kitchen garden national program. Available at: (accessed 10 November 2009). Department of Education and Early Childhood Development. Sport sportsperson in schools program. Available at: (accessed 10 November 2009). Department of Education Tasmania. Move well eat well. Available at: (accessed 10 November 2009). Government of South Australia. Eat well be active. Available at: (accessed 10 November 2009). Government of South Australia. Eat well SA healthy eating guidelines for SA school and preschools (Healthy Eating Guidelines). Available at: (accessed 8 November 2009). Government of South Australia. Food and nutrition. Availability at: (accessed 9 November 2009). Government of Western Australia, Department of Health. Crunch and sip. Available at: (accessed 10 November 2009). Government of Western Australia. Star canteen accreditation program. Available at: (accessed 5 November 2009). Healthy Kids. Go for your life healthy canteen policy. Available at: (accessed 10 November 2009). National Heart Foundation of Australia. Eat smart play smart. Available at: (accessed7 November 2009). New South Wales Health Department. Healthy school canteens. Available at: (accessed 10 November 2009). Northern Territory Government. goNT. Available at: (accessed 9 November 2009). Northern Territory Government. Schools network. Available at (accessed 8 November 2009). NSW Department of Education and Training. Sport and physical activity safety policy for schools. Available at: (accessed 10 November 2009). Nutbeam, D. (1992) The health promoting school: closing the gap between theory and practice. Health Promotion International 7(3), 151–153. O'Dea, J., & Maloney, D. (2000) Prevention of eating and body image problems in children and adolescents using the health promoting schools framework. Journal of School Health 70(1), 18– 21.

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Smolak, L., Levine, M.L., Striegel-Moore, R.H. (Ed.) The developmental psychopathology of eating disorders, Lawrence Erlbaum, New Jersey, pp. 313–339. Sport and Recreation Tasmania, Department of Economic Development. Get moving Australia. Available at: (accessed 5 November 2009). State of Victoria. Child nutrition fruit + veg program. Available at: (accessed 10 November 2009). State of Victoria. Go for your life. Available at: (accessed 10 November 2009). The Parents Jury. School nutrition guidelines around Australia. Available at: (accessed 8 November 2009). The State of Queensland (Department of Education and Training) Active ate. Available at: (accessed 9 November 2009). The State of Queensland (Department of Education and Training). Be active Queensland (2006– 2010). Available at: (accessed 8 November 2009). The State of Queensland (Department of Education and Training). Healthy schools initiative. Available at: (accessed 5 November 2009). The State of Queensland (Department of Education and Training). Smart choices – healthy food and drink supply strategy for Queensland schools. Available at: (accessed 10 November 2009). The State of Queensland (Department of Education and Training). Smart moves physical activity programs in Queensland state schools. Available at: (accessed 10 November 2009). TSCA. What is the T.S.C.A.? Available at: (accessed 8 November 2009). Victorian Department of Planning and Community Development. Sport and recreation Victoria. Available at: (accessed 5 November 2009). Western Australia Physical Activity Taskforce. Be Active WA. Availability at: (accessed 10 November 2009). World Health Organization (1998) Health Promoting Schools. A healthy start for living, learning and working. WHO/HPR/HEP/98.4. Geneva: WHO.

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Interventions targeting childhood obesity involving parents

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Interventions targeting childhood obesity involving parents Nancy Espinoza Guadalupe X. Ayala Elva M. Arredondo

DOI:10.1093/acprof:oso/9780199572915.003.0026

Abstract and Keywords This chapter discusses the role of parents in the prevention of childhood obesity, with a particular focus on how best to involve parents in treatment as well as preventive efforts. Parental involvement differs widely from one study to the next, making it difficult to compare interventions and draw conclusions as to which approach may be the most effective. The chapter reviews international childhood obesity interventions that involved children or adolescents between the age of 2 through 19 and at least one parent. This review was not intended to be exhaustive but rather to examine select published literature.

Keywords: parents, parental involvement, overweight, obesity, children, intervention, eating disorders, prevention, education

Chapter summary This chapter discusses the role of parents in the prevention of childhood obesity, with a particular focus on how best to involve parents in treatment as well as preventive efforts. Parental involvement differs widely from one study to the next, making it difficult to compare interventions and draw conclusions as to which approach may be the most effective. The objective of this chapter is to review international childhood obesity interventions that involved children or adolescents between the age of 2 through 19 and at least one parent. This review was not intended to be exhaustive but rather to examine select published literature. Selected interventions included those conducted between 1999 and 2009 in order to represent the latest approaches to family-focused childhood obesity prevention.

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Interventions targeting childhood obesity involving parents

Importance of childhood overweight and obesity prevention and treatment interventions There is evidence to support that even a small decline in the number of new cases of childhood obesity would be meaningful, with some researchers even suggesting that this can be accomplished by changing energy balance by as little as 100 calories per day (Rodearmel et al., 2006). Parental influence is an important factor to consider when discussing childhood overweight and obesity and particularly important when designing interventions. Research supports parental involvement in interventions to prevent and reduce childhood overweight and obesity because parents play such an important role in a child’s life (McGarvey et al., 2004; Slawta et al., 2008; Wrotniak et al., 2004). Many health behaviours are learned early in a child’s life, including the development of food preferences (Birch & Davison, 2001; Savage et al., 2007) and eating patterns (Birch, 1999; Fisher & Birch, 2002). Because parents are most often responsible for food selection and meal structure (Slawta & Deneui, 2009), parental involvement in interventions targeting childhood obesity can help prevent unhealthy increases in a child’s BMI (Story et al., 2003a). Parents can also influence a child’s level of physical activity. Children are more likely to be active if their parents are physically active (Walters et al., 2003) and some research has even suggested that the relationship between parent and child physical activity levels may be moderated by the strength of the parent–child bond (Dzewaltowski et al., 2008). Parental overweight and obesity are also closely related to overweight and obesity among children (Harding et al., 2008). One study suggested that children with obese mothers were twice as likely to be overweight or obese compared with children with normal weight mothers (Kimbro et al., 2007). (p.301) Sufficient evidence supports the inclusion of parents in interventions to prevent and treat childhood obesity; however, there is no consensus yet on which type of intervention is the most effective (Harding et al., 2008; Story et al., 2003b). Currently, there is no structured framework for childhood obesity prevention interventions involving parents (Muller et al., 2001). Child-based interventions that involve parents vary by level of parental involvement. Some researchers support including the parent and child in the same intervention. Although this approach has shown some positive results (Beech et al., 2003), other researchers suggest that intervention strategies for children and adults should be different; therefore, interventions that separate the parent and child may be more effective (Kalavainen et al., 2007) in part because it may result in the child being less inhibited and more likely to actively participate when they are not in the presence of a parent (Golan et al., 2006).

Targeting small changes by involving both children and parents equally Rodearmel et al. (2006) designed an intervention to reduce weight gain in 8–12-year-old children who were overweight or at risk for becoming overweight. Sixty two families participated in the 13-week intervention, which analyzed BMI, steps taken per day, and servings of cereal consumed. The intervention families were encouraged to increase the number of steps they took per day, as measured by a pedometer, and to consume two servings of cereal per day. These families also met with the study staff on three occasions during the intervention. At the conclusion of the intervention, steps per day increased significantly over baseline among the

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Interventions targeting childhood obesity involving parents

intervention families and they consumed an average of one serving of cereal per day. BMI among children and parents who participated in the intervention showed significant trends towards a reduction in BMI whereas the control group showed an increase in BMI. The researchers concluded that family-based interventions that target small lifestyle changes can have an important impact on preventing excessive weight gain in children and their parents (Rodearmel et al., 2006). Other researchers have also concluded that encouraging healthy behaviour changes rather than focusing on weight loss should be the focus in childhood obesity interventions (Golan & Weizman, 2001; McCallum et al., 2005). In another study, 7–14-year-olds and their parents were encouraged to increase their number of steps per day and decrease their caloric consumption by using non-caloric sweetener instead of sugar. The researchers concluded that small lifestyle modifications were easy to implement and can help reduce excessive weight gain in intervention children (Rodearmel et al., 2007). This study highlights the importance of introducing small changes, which are easy to implement, rather than making changes that may not be sustainable once the intervention is over. The results also suggest that simply preventing excessive weight gain among children, rather than focusing on weight loss, may be the first step towards preventing childhood obesity.

Child-based interventions with parental involvement An intervention to evaluate the effects of a hospital-based, family-centred lifestyle programme to improve the health of 264 overweight children included weekly nutrition, exercise, education, behaviour modification, and family involvement sessions (Dreimane et al., 2007). The original programme was designed as an 8-week intervention but later extended to a 12-week programme because the researchers determined that 8 weeks was not long enough to achieve change. The weekly sessions were 90 minutes in duration and parents were involved in all aspects of the intervention except the exercise portion. While the intervention children attended the exercise sessions, parents (p.302) attended educational classes on how to provide a supportive environment for their child. Parents were also taught about the implications of obesity and the importance of leading a healthy lifestyle. At the conclusion of the intervention, parents reported that they perceived their child to be healthier as a result of the intervention and children reported an improvement in self-perceived health and well-being. There were statistically significant decreases in child weight and BMI velocity. However, the intervention had a low retention rate (31%), which limits the generalizability of study findings. The researchers concluded that because the intervention families were of a relatively lower socioeconomic status, transportation and language could have been barriers that affected the retention rate and that perhaps a mobile weight management programme would have been a better strategy for this population (Dreimane et al., 2007). Taking transportation barriers into consideration, White et al. (2004) designed an internet-based intervention that also involved parents in all aspects of the intervention. Parent–child groups were randomized into a behavioural or control condition and participated in a 2-year programme that included receiving a computer for their home and free internet access. Participants were asked to log in to a specific web site weekly and access weight loss, nutrition, and physical activity material. In addition to these materials, the behavioural group was provided with a case manager who could be reached via email plus additional intervention material including forms for self-monitoring, goal setting, problem solving, behavioural contracting, and relapse

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prevention. The control group received information on serving sizes, the food pyramid, calories, and food labels. Despite providing these families with access to the internet, results from the first 6 months of the intervention revealed an overall decline in adherence after the first 3 months, with adherence defined as the number of times participants visited the website and the number of quizzes completed. Nevertheless, small decreases in body fat (measured using DEXA procedure) and BMI were observed for both the parents and children in the behavioural group. Given the modest changes in body fat and BMI among the intervention group, the results indicate that an internet-based intervention may not be as effective as a face-to-face intervention (White et al., 2004). Other studies have also reported increased intervention benefits as the result of increased contact with researchers, health professionals, or other intervention participants (Burke et al., 2006). In addition, similar to this intervention, low adherence (Baranowski et al., 2003) and decreasing log-on rates have been a problem in other internetbased studies (Cullen et al., 2008). However, the results do highlight the importance of integrating behavioural change components into childhood overweight and obesity interventions (White et al., 2004). Internet interventions have the potential of reaching more people and can be more cost effective than individual treatment programmes. However, more research is needed on internet-based programmes to determine their effectiveness.

Child-based interventions with limited parental involvement An intervention by Nemet and colleagues (2005) included children and adolescents from 6 to16 years of age. Participants attended evening lectures with their parent(s) and met with a dietitian six times during the intervention. The intervention children and adolescents also participated in a physical activity programme throughout the intervention. Measurements were taken at 3 months post-intervention and at 1 year post-intervention. At 3 months post-intervention, there was a significant decrease in BMI among intervention children and adolescents and no change in BMI among the control group. At 1 year post-intervention, the intervention group showed a significant decrease in BMI compared with an increase in BMI among the control group. Results from this intervention indicate that involving parents in some but not all aspects of the intervention may be an effective strategy in the prevention of childhood obesity. In addition, this intervention (p.303) highlights the importance of multifaceted interventions that address nutrition and physical activity. Similarly, in an intervention conducted at six randomized Head Start early childhood centres, parents and children participated in different aspects of the intervention. Children engaged in 14 weeks of health education and physical activity classes while parents received a weekly newsletter accompanied by a homework assignment meant to be completed by the parent and child. There were no statistical differences in BMI between the intervention group and the control group immediately following this intervention or at the 1- and 2-year follow-ups. In addition, there were also no differences in dietary intake and physical activity between the intervention and control groups. The researchers suggest that the level of parental involvement may not have been intensive enough, raising the question of exactly how much and what type of parental involvement is needed to produce health behaviour and BMI changes among children. The researchers also address the need for interventions to address the family environment (Fitzgibbon et al., 2006). Addressing the family, rather than just the child and parent, may help to create a more supportive home environment, and thus a more effective intervention.

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In another intervention that involved 95 overweight or obese children between 7 and 15 years old and their families, parental involvement was also limited. However, unlike the previous study, this study resulted in a decrease in BMI. During this 12-month intervention, children participated in bi-weekly behavioural therapy sessions while parents participated in a separate parent course. Children also participated in a bi-weekly dietary training course and a physical activity programme throughout the 12-month intervention. Parents did not participate in the dietary training and physical activity programme, but were offered monthly individual or group meetings. The results of this intervention showed a significant reduction in BMI for the majority of intervention participants. An important finding from this study was that children with significant BMI reductions were younger than those who did not achieve a significant BMI reduction. This finding suggests that overweight and obesity interventions may be most effective among a younger audience (Pott et al., 2009). Other researchers have also suggested that early treatment and prevention of obesity is of paramount importance (Nemet et al., 2005). An intervention among young mothers with children younger than 5 years of age showed a positive trend towards weight reduction and resulted in a significant reduction in energy intake among the children in the intervention group, suggesting that interventions involving parents can be beneficial for young children (Harvey-Berino & Rourke, 2003). Another reason that the previous intervention by Pott et al. (2009) may have been effective was that it was longer than most interventions. A 12-month intervention provides ample time to see a reduction in BMI. Extending interventions even a few weeks can make a difference in the results (Dreimane et al., 2007). Longer interventions and interventions that provide ongoing monitoring and support once the intervention is over could have a significant impact on the success of health interventions and the prevention of childhood obesity (Nemet et al., 2005).

Parent-based interventions with child involvement Much like child-based interventions, parent-based interventions also vary as to the level of parental involvement. Parent-based interventions attempt to impact children’s behaviour indirectly through increasing parental education and involvement (Cottrell et al., 2005). A parent-based study conducted in Britain specifically addressed the food purchased and served in the home, modes of transportation, and leisure-time activities. Parents were given strategies to make changes around eating behaviour and physical activity. The intervention included 12 separate sessions for parents and children, which included behaviour modification techniques. (p.304) At the conclusion of the intervention, children lost 8.4% BMI and had maintained that loss when re-assessed at the 3-month follow-up. Children also reported increased self-esteem and decreased depressive symptoms, which could have been a result of parental involvement in the intervention and children’s perception of increased support (Edwards et al., 2006). This intervention also utilized goal-setting techniques, which have been shown to be beneficial among children and adolescents in dietary or physical activity interventions (Shilts et al., 2004). Childhood obesity prevention interventions may be enhanced by incorporating individualized and non-competitive goals (Slawta et al., 2008). In another parent-based intervention, 60 African American girls aged 8–10 and their parents participated in a culturally tailored family-based intervention that included two separate components for children and parents. Both components of the intervention addressed healthy

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eating and increased physical activity but each utilized a different approach. For example, while children were taught fun activities for movement and encouraged to eat a variety of healthy foods, parents learned ways to increase family activity and participated in many cooking activities. The intervention did not result in a significant decrease in BMI but did demonstrate a trend towards a reduced BMI (Beech et al., 2003). This study highlights the importance of tailoring interventions to specific target audiences, including making them culturally appropriate and sensitive to ethnic differences. Appropriately tailored interventions have shown positive results. Davis et al. (2003) demonstrated that a physical activity and healthful eating intervention that incorporated culturally appropriate concepts and traditions was successful in introducing children and their families to information about how to lead a healthy lifestyle.

Parent-based interventions with no child involvement Many parent-focused interventions incorporate behavioural modeling and parenting skills. Research suggests that interventions that include behavioural changes can be very effective (Edwards et al., 2006; McCallum et al., 2005; White et al., 2004). Parenting skills training is an important component of family-based interventions (Golley et al., 2007) and is supported by childhood obesity prevention research (Golan & Weizman, 2001). Interventions that utilize parents as the agent of change and address parenting styles and parenting skills have been shown to influence changes in parent’s and children’s exercise and nutrition habits (Golan, 2006; Golan & Crow, 2004; Golan & Weizman, 2001). An intervention by Golley et al. (2007) was designed to evaluate the effectiveness of parenting skills in the treatment and prevention of childhood overweight and obesity. A randomized control trial was used to assign participants to a parenting skills and lifestyle education group, a parenting skills only group, or a control group. Children were not directly involved in this intervention and did not attend any of the intervention sessions. The results showed a decrease in BMI among all three groups, leading the researchers to conclude that parenting skills training and education regarding lifestyle changes are both important aspects of childhood obesity prevention interventions. Golan et al.(2006) reported that in an intervention that included parents of a child between the age of 6 and 11 as the main agents of change and had no child involvement resulted in a greater BMI decrease than the group that involved parents and children. These results still applied at the 1-year follow-up for both groups. The researchers also reported that during the intervention there was higher attendance among the parent-only group (Golan et al., 2006). However, other research has shown that attendance among intervention participants was higher when children were involved (Jones et al., 2009). In other interventions that involved parents only, it was concluded that interventions that involved only the parents were more effective, as compared to those involving parents and (p. 305) children or just children (Golan, 2006; Golan & Crow, 2004; Golan et al., 2006). Familybased interventions with parents as the agents of change that include goal setting, and incorporate behaviour change and effective parenting tools appear to be an effective strategy in the prevention of childhood obesity.

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Group treatment versus individual treatment Research on group treatment compared to individual treatment has shown mixed results. Some studies suggest that group and individual treatment are both effective (de Mello et al., 2004), whereas other studies have concluded that family-based group treatment is more successful than individual treatment (Garipa ˘g ao ˘g lu et al., 2009; Kalavainen et al., 2007). Advantages of group interventions include group support, group learning, and group optimism, which may increase success in long-term weight maintenance in adults and children. Seventy obese children participated in a study that tested the outcomes of group-based treatment versus routine counseling (Kalavainen et al., 2007). The duration of this intervention was 6 months and the follow-up measures were done at 6 months post-intervention. The children were assigned to routine counseling, which involved two individual counseling sessions or a group treatment programme, which consisted of 15 family centred sessions. The family centred sessions included behavioural and solution-oriented therapy whereas the routine sessions were based on self-knowledge. The children in group treatment had a significant decrease in BMI when compared to children who underwent routine treatment, leading the researchers to conclude that group treatment is more effective than routine treatment when dealing with obese children (Kalavainen et al., 2007). However, the intervention dose provided to each condition was notably different; the routine treatment condition received two sessions whereas the other received 15 sessions. This difference makes it difficult to compare the conditions and draw strong conclusions. Giving both conditions the same intervention dose would have made the results more comparable and would have strengthened the conclusion that group treatment is more effective than individual treatment. Other researchers have also drawn similar conclusions about the effectiveness of individual versus group treatment. De Mello et al. (2004) compared individual outpatient treatment and group education programmes to determine which would lead to greater improvements in dietary and physical activity behaviour. In this intervention children either attended monthly meetings alone or attended lectures in a group. Parents were also put into groups where they could discuss problems and effective techniques for improving dietary behaviour. At the conclusion of the intervention, the children in the individual group reduced their level of inactivity whereas all the other variables remained the same. The children in the group treatment showed increases in physical activity and a reduction in BMI. However, the percentage reductions in BMI did not reach statistical significance. Aside from supporting group education programmes over individual programmes, the researchers also noted that group treatment is cost effective and can treat a greater number of people than individual interventions (de Mello et al., 2004).

Future research More needs to be learned about how to entice participation and enhance parental involvement. Assessing the family’s readiness for change may be the first step towards determining adherence and compliance. Given that 50% of individuals who start an exercise programme do not adhere to the programme more than 6 months (White et al., 2004), there is a need for more research on exercise adherence and intervention longevity (Rodearmel et al., 2007).

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(p.306) Conclusions It appears that interventions with a nutrition and physical activity component that include education, behaviour modification, and parent skills training is an effective strategy for the prevention and treatment of childhood obesity. It also seems that group treatment may be beneficial for participants and is a valid way of reaching a greater number of individuals at one time. The need for well-designed studies remains a priority.

Acknowledgement This work was supported by the American Cancer Society (Dr. Ayala), the San Diego Prevention Research Center [U48DP001917-01] (Drs. Ayala and Arredondo), the Robert Wood Johnson Foundation [65337] (Dr. Arredondo), and by award number T32GM084896 (PI: M.Hovell) from the National Institute of General Medical Sciences (Nancy Espinoza). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of General Medical Sciences or the National Institutes of Health. References Bibliography references: Baranowski, T., Baranowski, J.C., Cullen, K.W., et al. (2003) The fun, food, and fitness project (FFFP): The Baylor Gems pilot study. Ethnicity & Disease 13, S130–S39. Beech, B.M., Klesges, R.C., Kumanyika, S.K., et al. (2003) Child- and parent-targeted interventions: the Memphis GEMS pilot study. Ethnicity & Disease 13(1 Suppl 1), S40–S53. Birch, L.L. (1999) Development of food preferences. Annual Review of Nutrition 19, 41–62. Birch, L.L. & Davison, K.K. (2001) Family environmental factors influencing the developing behavioral controls of food intake and childhood overweight. Pediatric Clinics of North America 48(4), 893–907. Burke, S.M., Carron, A.V., Eyes, M.A., Ntoumanis, N., & Estabrooks, P.A. (2006) Group versus individual approach? A meta-analysis of the effectiveness of interventions to promote physical activity. Sport & Exercise Psychology Review 2, 13–29. Cottrell, L., Spangler-Murphy, E., Minor, V., Downes, A., Nicholson, P., & Neal, W.A. (2005) A kindergarten cardiovascular risk surveillance study: CARDIAC-kinder. American Journal of Health Behavior 29(6), 595–606. Cullen, K.W., & Thompson, D. (2008) Feasibility of an 8-week African American Web-based Pilot Program Promoting Healthy Eating Behaviors: Family Eats. American Journal of Health Behavior 32(1), 1087–3244. Davis, S.M., Clay, T., Smyth, M., et al. (2003) Pathways curriculum and family interventions to promote healthful eating and physical activity in American Indian schoolchildren. Preventive Medicine 37(6 Pt 2), S24–S34.

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de Mello, E.D., Luft, V.C., & Meyer, F. (2004) [Individual outpatient care versus group education programs. Which leads to greater change in dietary and physical activity habits for obese children?]. Jornal De Pediatria 80(6), 468–474. Dreimane, D., Safani, D., MacKenzie, M., et al. (2007) Feasibility of a hospital-based, familycentered intervention to reduce weight gain in overweight children and adolescents. Diabetes Research and Clinical Practice 75(2), 159–168. Dzewaltowski, D.A., Ryan, G.J., & Rosenkranz, R.R. (2008) Parental bonding may moderate the relationship between parent physical activity and youth physical activity after school. Psychology of Sport and Exercise 9(6), 848–854. Edwards, C., Nicholls, D., Croker, H., Van Zyl, S., Viner, R., & Wardle, J. (2006) Family-based behavioural treatment of obesity: acceptability and effectiveness in the UK. European Journal of Clinical Nutrition 60, 587–592. Fisher, J.O. & Birch, L.L. (2002) Eating in the absence of hunger and overweight in girls from 5 to 7 y of age. The American Journal of Clinical Nutrition 76(1), 226–231. Fitzgibbon, M.L., Stolley, M.R., Schiffer, L., Van Horn, L., KauferChristoffel, K., & Dyer, A. (2006) Hip-Hop to Health Jr. for Latino preschool children. Obesity 14(9), 1616–1625. Garipa ˘g ao ˘g lu, M., Sahip, Y., Darendeliler, F., Akdikmen, O., Kopuz, S., & Sut, N. (2009) Family-based group treatment versus individual treatment in the management of childhood obesity: randomized, prospective clinical trial. European Journal of Pediatrics 168(9), 1091– 1099. Golan, M. (2006) Parents as agents of change in childhood obesity – from research to practice. International Journal of Pediatric Obesity 1(2), 66–76. Golan, M. & Crow, S. (2004) Targeting parents exclusively in the treatment of childhood obesity: long-term results. Obesity Research 12(2), 357–361. Golan, M. & Weizman, A. (2001) Familial approach to the treatment of childhood obesity: conceptual mode. Journal of Nutrition Education 33(2), 102–107. Golan, M., Kaufman, V., & Shahar, D.R. (2006) Childhood obesity treatment: targeting parents exclusively v. parents and children. The British Journal of Nutrition 95(5), 1008–1015. Golley, R.K., Margarey, A.M., Baur, L.A., Steinbeck, K.S., & Daniels, L.A. (2007) Twelve-month effectiveness of a parent-led, family-focused weight-management program for prepubertal children: a randomized, controlled trial. Pediatrics 119, 517–525. Harding, S., Teyhan, A., Maynard, M.J., & Cruickshank, J.K. (2008) Ethnic differences in overweight and obesity in early adolescence in the MRC DASH study: the role of adolescent and parental lifestyle. International Journal of Epidemiology 37(1), 162–172.

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Harvey-Berino, J. & Rourke, J. (2003) Obesity prevention in preschool Native-American children: a pilot study using home visiting. Obesity Research 11(5), 606–611. Jones, R.A., Warren, J.M., Okely, A.D., et al. (2009) Process evaluation of the Hunter Illawarra kids challenge using parent support study: a multisite randomized controlled trial for the management of child obesity. Health Promotion Practice. Available at 〈〉 [Accessed 30 November 2009]. Kalavainen, M.P., Korppi, M.O., & Nuutinen, O.M. (2007) Clinical efficacy of group-based treatment for childhood obesity compared with routinely given individual counseling. International Journal of Obesity 31(10), 1500–1508. Kimbro, R.T., Brooks-Gunn, J., & McLanahan, S. (2007) Racial and ethnic differentials in overweight and obesity among 3-year-old children. American Journal of Public Health 97(2), 298–305. McCallum, Z., Wake, M., Gerner, B., et al. (2005) Can Australian general practitioners tackle childhood overweight/obesity? Methods and processes from the LEAP (Live, Eat and Play) randomized controlled trial. Journal of Paediatrics and Child Health 41(9–10), 488–494. McGarvey, E., Keller, A., Forrester, M., Williams, E., Seward, D., & Suttle, D.E. (2004) Feasibility and benefits of a parent-focused preschool child obesity intervention. American Journal of Public Health 94(9), 1490–1495. Muller, M.J., Mast, M., Asbeck, I., Langnase, K., & Grund, A. (2001) Prevention of obesity – is it possible? Obesity Reviews 2, 15–28. Nemet, D., Barkan, S., Epstein, Y., Friedland, O., Kowen, G., & Eliakim, A. (2005) Short- and long-term beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity. Pediatrics 115(4), e443–449. Pott, W., Albayrak, O., Hebebrand, J., & Pauli-Pott, U. (2009) Treating childhood obesity: family background variables, the child's success in a weight-control intervention. The International Journal of Eating Disorders 42(3), 284–289. Rodearmel, S.J., Wyatt, H.R., Stroebele, N., Smith, S.M., Ogden, L.G., & Hill, J.O. (2007) Small changes in dietary sugar and physical activity as an approach to preventing excessive weight gain: the America on the Move family study. Pediatrics 120(4), e869–879. Rodearmel, S.J., Wyatt, H.R., Barry, M.J., et al. (2006) A family-based approach to preventing excessive weight gain. Obesity 14(8), 1392–1401. Savage, J.S., Fisher, J.O., & Birch, L.L. (2007) Parental influence on eating behavior: conception to adolescence. The Journal of Law, Medicine & Ethics 35(1), 22–34. Shilts, M.K., Horowitz, M., & Townsend, M.S. (2004) Goal setting as a strategy for dietary and physical activity behavior change: a review of the literature. American Journal of Health Promotion 19(2), 81–93.

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Slawta, J.N. & Deneui, D. (2009) Be a fit kid: nutrition and physical activity for the fourth grade. Health Promotion Practice. Available at: 〈〉 [Accessed 30 November 2009]. Slawta, J., Bentley, J., Smith, J., Kelly, J., & Syman-Degler, L. (2008) Promoting healthy lifestyles in children: a pilot program of be a fit kid. Health Promotion Practice 9(3), 305–312. Story, M., Sherwood, N.E., Himes, J.H., et al. (2003a) An after-school obesity prevention program for African-American girls: the Minnesota GEMS pilot study. Ethnicity & Disease 13(1 Suppl 1), S54–64. Story, M., Snyder, M.P., Anliker, J., et al. (2003b) Changes in the nutrient content of school lunches: results from the Pathways study. Preventive Medicine 37(6 Pt 2), S35–45. Walters, P.H., Holloman, A., Blomquist, L., & Bollier, M. (2003) Childhood obesity: causes and treatment. ACSM's Health & Fitness Journal 7(1), 17–22. White, M.A., Martin, P.D., Newton, R.L., et al. (2004) Mediators of weight loss in a family-based intervention presented over the internet. Journal of Obesity Research 12(7), 1050–1059. Wrotniak, B.H., Epstein, L.H., Paluch, R.A., & Roemmich, J.N. (2004) Parent weight change as a predictor of child weight change in family-based behavioral obesity treatment. Archives of Pediatrics & Adolescent Medicine 158(4), 342–347.

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Promoting optimal weights in Aboriginal children in Canada through ecological research

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Promoting optimal weights in Aboriginal children in Canada through ecological research Ashlee-Ann E. Pigford Noreen D. Willows

DOI:10.1093/acprof:oso/9780199572915.003.0027

Abstract and Keywords The general health of Aboriginal peoples in Canada is poorer than that of non-Aboriginal peoples. In particular, obesity-related chronic diseases like type 2 diabetes (T2D) disproportionately affect the Aboriginal population. This chapter suggests that an ecological approach is needed to promote effectively and support healthy body weights among Aboriginal children in Canada. It provides an overview of important research findings, the current state of knowledge, and the research gaps regarding the determinants of healthy weights in Aboriginal children. It presents two case studies of First Nations community-based interventions to illustrate the application of the ecological framework to address children's weight status. Each intervention focused on changing knowledge, attitudes, and behaviours surrounding dietary practices, physical activity, and health beliefs. The chapter concludes by suggesting future research activities to better understand or modify the social determinants of health as an approach to improving Aboriginal children's weight status.

Keywords: type 2 diabetes, obesity, children, intervention, culture, community, ethnic, Aboriginal, indigenous, Canada

Chapter summary The general health of Aboriginal peoples in Canada is poorer than that of non-Aboriginal peoples. In particular, obesity-related chronic diseases like type 2 diabetes (T2D) disproportionately affect the Aboriginal population. We suggest that an ecological approach is needed to effectively promote and support healthy body weights among Aboriginal children in Canada. This chapter will provide an overview of important research findings, the current state

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of knowledge, and the research gaps regarding the determinants of healthy weights in Aboriginal children. Two case studies of First Nations community-based interventions are presented to illustrate the application of the ecological framework to address children’s weight status. Each intervention focused on changing knowledge, attitudes, and behaviours surrounding dietary practices, physical activity, and health beliefs. We conclude by suggesting future research activities to better understand or modify the social determinants of health as an approach to improving Aboriginal children’s weight status.

Canada’s Aboriginal population Population description Aboriginal peoples are the descendants of the original inhabitants of North America. The 1982 Constitution Act, section 35(2) of Canada recognizes three groups of Aboriginal peoples – North American Indian, Métis, and Inuit – each having unique heritages, languages, cultural practices, and spiritual beliefs. North American Indians (First Nations) are Aboriginal persons who are neither Inuit nor Métis. The Inuit originally lived in Canada’s arctic and sub-arctic regions. Métis are of mixed First Nations (typically Ojibway or Cree) and European (typically Scottish or French) ancestry (Indian and Northern Affairs Canada, 2003). Over one million respondents representing 4% of the total Canadian population identified themselves as Aboriginal in the 2006 Canadian Census (Cloutier et al., 2008). In that census, children and youth aged 24 and under made up almost one-half (48%) of all Aboriginal people, compared with 31% of the non-Aboriginal population (Cloutier et al., 2008). This demographically young Aboriginal population is experiencing growth nearly 6 times greater than the rest of the population (Cloutier et al., 2008). The health status of Aboriginal peoples is poorer than that of the general population and obesity and T2D are major health problems (Gracey & King, 2009; Liu et al., 2006; McShane et al., 2009; Shields, 2006; Young et al., 2000). The age-standardized prevalence of T2D among First Nations is 3–5 times that of the general population and T2D has been reported among First Nations children (p.310) as young as 12 years of age (Dean et al., 1998; McShane et al., 2009; Young et al., 2000). Inuit are, however, less likely to be diagnosed with T2D, heart disease, and high blood pressure than other Canadian Aboriginals (Tait, 2008). Nonetheless, increasing rates of obesity in Inuit children and adults forewarn of the emergence of cardiovascular disease and T2D in the future (Charbonneau-Roberts et al., 2007; Egeland et al., 2009; Egeland et al., 2010; Kuhnlein et al., 2004). Additionally, very little is known about the burden of T2D within the Métis population; however, one study in the province of Alberta suggests that Métis are experiencing an emerging chronic disease epidemic similar to that of First Nations people (Oster & Toth, 2009). Childhood obesity – national evidence The available national data suggest that Aboriginal children have a higher prevalence of obesity than the general pediatric population of Canada. National evidence is limited to two studies. Results from the 2004 Canadian Community Health Survey indicate the obesity prevalence for off-reserve Aboriginal (mostly First Nation) children is 20% obese, which is two and one-half times the national average for children (8.2% obese) (Shields, 2006). The 2002–2003 First Nations Regional Longitudinal Health Survey indicated that 58.5% of the surveyed children aged 3–11 years living on-reserve were overweight (22.3%) or obese (36.2%).

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Childhood obesity – regional evidence Recent community-based studies, although small in number compared to the hundreds of Aboriginal communities across the country, support the findings of high obesity prevalence found in children included in national surveys. Obesity has only recently been specifically documented in Inuit children but Inuit and Yukon adults have obesity rates that exceed the rest of Canada (Charbonneau-Roberts et al., 2007; Kuhnlein et al., 2004). If the results from the select communities are typical of the entire Aboriginal population, then obesity in Aboriginal children and youth is a great public health concern. ◆ Inuit pre-school children (age 3–5 years) in Nunavut: 39.3% overweight and 28.0% obese (Egeland et al., 2010) ◆ Cree First Nation school children (age 9–12 years) in Quebec: 29.9% overweight and 39.3% obese (Downs et al., 2009) ◆ Cree First Nation preschool (age 5 years) children in Quebec: 31.6% overweight and 21.3% obese (Willows et al., 2007) ◆ Cree First Nation school children (age 5–12 years) in Alberta: 27.6% overweight and 20.0% obese (Pigford, 2010) ◆ Ojibway-Cree First Nation children (age 2–19 years) in Sandy Lake Ontario: 27.7% of boys and 33.7% of girls obese (Hanley et al., 2000) ◆ Mohawk First Nation school children (age 5–12 years) in Kawnawake Quebec: 29.5% of boys and 32.8% of girls obese (Trifonopoulos, 1995) ◆ Dene/Metis and Yukon children in the Western Arctic (age 10–12 years): 13% overweight and 18% obese (Nakano et al., 2005) ◆ St Theresa Point First Nation in northern Manitoba (age 4–19 years): 48% of girls and 51% of boys obese (Dean et al., 1998) ◆ Tsimshian First Nation youth on the West Coast (age 6–18 years): 19.3% overweight and 26.0% obese (Zorzi et al., 2009) ◆ Woodland Cree youth (age 7–17 years) in Saskatchewan: 26% overweight/obese (Bruner et al., 2009) (p.311) The central distribution of fat mass in Aboriginal peoples indicates increased obesityrelated health risk (Bruner et al., 2009; Katzmarzyk & Herman, 2007; Liu et al., 2007). The combination of obesity and upper body fat patterning found in geographically distinct First Nations communities suggests that First Nations children with excess weight are at high risk for obesity related comorbidities. For example, 36% of Tsimshian youth have abdominal obesity (Zorzi et al., 2009). Among the Cree of northern Quebec, half (52.2%) of elementary school children are abdominally obese (Downs et al., 2008). In Alberta, 48.5% of Cree school children in one community are abdominally obese (Pigford, 2010). Based on skinfold thickness data, excess weight is also centrally distributed in Mohawk children in Kanawake Quebec (Potvin et al., 1999).

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Lifestyle practices detrimental to maintenance of a healthy body weight are also of concern. Where data on dietary intake or physical activity patterns have been recorded, irrespective of weight status, Aboriginal children have low physical activity levels, poor physical fitness, and consume energy dense diets with high consumption of sweetened beverages and snack foods and low consumption of nutrient rich foods and traditional foods (Downs et al., 2008; Downs et al., 2009; Gittelsohn et al., 1998; Jimenez et al., 2003; Nakano et al., 2005; Pigford, 2010). Considering these findings, there is a need for ecological interventions which consider both the non-environmental (e.g., personal health practices, knowledge, attitudes, capacity, and perceived barriers) and environmental (e.g., social, physical, and economic factors) determinants of healthy weights in Aboriginal communities.

Aboriginal childhood obesity and the ecological framework The ecological framework defined Childhood obesity is a public health problem with a multidimensional nature. How children live, play, eat and drink, spend their leisure time, get to school, etc. are not merely individual choices, but often have social, cultural, economic, and environmental determinants (Wilkinson & Marmot, 2003). For this reason, prevention and treatment interventions for childhood obesity that have overlooked social and environmental influences often have had little impact (Ebbeling et al., 2002; Mayor, 2002). An ecological model offers a framework to account for the reciprocal interaction of individual behaviours and the environment in the development of obesity. It suggests that a child’s weight status is not only influenced by the energy intake and expenditure patterns of that child, but is embedded within the larger ecology of the child’s family, community, and demographic characteristics (Birch & Ventura, 2009). In the ecological framework, interrelationships between a child's individual dimensions (i.e., biomedical, attitudinal, and behavioural) with the multiple components of his or her life context (i.e., social, organizational, community, public policy, and physical environments) are examined (Plotnikoff et al., 2008). The determinants of health are factors that influence health and work synergistically on individual, community and societal levels. The social determinants of health form the basis of the ecological model. They include: individual (physiological, behavioural, and psychosocial) risk factors such as lack of social support; low self-esteem; and population risk conditions such as: poverty and inequity; low social status (education, employment); and discrimination (gender, race) (Laverack, 2004; Raphael, 2006). Aboriginal peoples may also have unique social determinants of health that influence their risk for obesity not typically discussed in the literature such as cultural beliefs and practices, and food insecurity (Willows, 2004; 2005a; Willows et al., 2009a; 2009b). Canada, and the ecological model Canada is recognized as a leader in the development of the social determinants of health concept demonstrated by early publications including the Lalonde Report (Lalonde, 1974), the (p.312) Ottawa Charter (World Health Organization, 1986), and the Epp Report (Epp, 1986; Jackson & Riley, 2007). Unfortunately, in Canada the ecological approach remains subordinate to biomedical and behavioural paradigms making Canada less successful than other nations in implementing actions to modify the social determinants to improve population health (Collins &

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Promoting optimal weights in Aboriginal children in Canada through ecological research

Hayes, 2007; Raphael, 2007). In particular, in Aboriginal populations there has been little exploration of how the social determinants are related to health outcomes. The greater burden of poor health in Aboriginal people is largely due to the social determinants of health such as poverty, cultural barriers, and jurisdictional problems (Bougie, 2009; Cloutier et al., 2008; Health Canada, 2009; Willows et al., 2009a). Compared with the general Canadian population, Inuit and First Nations have lower average incomes, lower labour force participation rates, higher unemployment rates, and lower completion rates for secondary and postsecondary education (Bougie, 2009; Cloutier et al., 2008; Hull, 2000; Tait, 2008; Wilkins et al., 2008; Willows et al., 2009a). Improving the health of Aboriginal people will therefore depend on improving their economic and social conditions as well as understanding cultural influences on health. Social determinants of health: cultural beliefs and practices Culture is broadly defined as the values, beliefs, attitudes, and practices accepted by members of a group or community and may influence an individual’s perception of their well-being (Garroutte et al., 2006). Culture influences the way people interact with the health care system, their participation in programmes of disease prevention and health promotion, access to health information, health related lifestyle choices, their understanding of health and illness, and their health priorities. For this reason, cultural beliefs may make an important contribution to both the health and weight status of Aboriginal children (Willows, 2004, 2005a; Willows et al. 2009b). The idea of health for many Aboriginal peoples is a balance between the physical, mental, emotional, spiritual, and social factors of life. The Métis Centre of the National Aboriginal Health Organization indicated, for example, that for the Métis, taking a holistic approach to health is important. Métis elders perceive well-being as dependent on the land and water as well as a wide range of social, cultural, political, and economic influences (Métis Centre, National Aboriginal Health Organization, 2008). Social support is a key determinant for Inuit health, and social networks often involve traditional food systems (sharing in hunting, harvesting, preparing food, making traditional garments, and community feasts) which, as a result, influences weight status (Egeland et al., 2009; Richmond et al., 2007). For the Cree of northern Quebec, the traditional concept of health is best conceived as miyupimaatisiiun, which means ‘being alive well’. Warmth, Cree food, and strength form the essence of ‘being alive well’ for the Cree (Adelson, 2000) and fat in food is considered nourishing and healthy (Boston et al., 1997). ‘Healthy living’ is conceptualized by both old and young Cree as life in the bush (Vallianatos et al., 2008). In part, culture dictates body size preferences and shapes eating behaviours by defining which foods are acceptable and preferable, the amount and combinations of foods to eat, when and how to eat, and the foods considered ideal or improper to eat (Kittler & Sucher, 2004). All cultures do not see obesity as a health problem and even if the risks of being overweight are known, there may be little social motivation to support sustained weight loss efforts (Davis et al., 2000). Ojibway–Cree in Ontario show a preference for large body size, especially older adults who associate thinness with infectious diseases such as tuberculosis (Gittelsohn et al., 1996). Among Quebec Cree extra weight is considered a sign of robustness and strength (Boston et al., 1997) and this belief would therefore potentially create a cultural context where larger body

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Promoting optimal weights in Aboriginal children in Canada through ecological research

sizes are preferred (Willows et al., 2009b). Indeed, some Quebec Cree children with a healthy body weight consider themselves to be too small; whereas other children with excess weight consider their body size to be just right. On the other hand, obese Cree children are more likely than their thinner counterparts to (p.313) consider their body size too big (Willows et al., 2009b). It may be that Quebec Cree children desire a large body size, or consider larger body sizes to be normal given the prevalence of obesity in the communities, yet are also influenced by images and perceptions outside their culture viewed on TV or in print. Certainly not all Aboriginal peoples value larger body sizes. In the United States, many American Indian children have expressed body size dissatisfaction and have concerns about weight, leading to unhealthy weight control practices and eating disorders (Davis & Lambert 2000; Neumark-Sztainer et al., 1997; Rinderknecht & Smith, 2002; Story et al., 1994). In Canada, First Nations and Métis girls and women living in urban Manitoba prefer thin body sizes and may use dieting to control their weight (Marchessault, 2001). Some First Nations women reportedly feel fat in urban areas dominated by ‘white culture’ but feel thinner in their home communities where their Aboriginal culture predominates (Fleming et al., 2006). The range of preferences for body size among Aboriginal people suggests that socio-cultural factors may influence the prevalence of childhood obesity. Social determinants of health: food security Food insecurity exists whenever the availability of nutritionally adequate and safe foods or the ability to acquire acceptable foods in socially acceptable ways is limited or uncertain (Anderson, 1990). Aboriginal people have higher levels of poverty and the determinants of poverty making them more likely to endure food insecurity and severe food insecurity with hunger than nonAboriginal persons (Chan et al., 2006; Health Canada, 2007; Lawn & Harvey, 2004; Power, 2008; Willows et al. 2005; Willows et al. 2009a). Recent analysis of the 2004 Canadian Community Health Survey indicated that 33% of off-reserve Aboriginal households were food insecure as compared with 9% of non-Aboriginal households. Furthermore, 14% of Aboriginal households had severe food insecurity often associated with hunger (Willows et al., 2009b). Although Canada’s Action Plan on Food Security (1998) acknowledges that actions to improve food security for Aboriginal peoples are important, Canada lacks a coherent and coordinated approach to address food security (Power, 2005; Slater, 2007). Food security is a primary concern throughout northern Canada and federal government initiatives such as the Food Mail Plan and the Canada Prenatal Nutrition Program are available in some Aboriginal communities, but for the most part communities must rely on ad hoc food programmes (Lawn & Harvey, 2003, 2004; Power, 2005, 2008; Slater, 2007). Food security is an important determinant of health for Aboriginal peoples that must be addressed to reduce health inequities such as childhood obesity (Power, 2005, 2008). Many Canadian children in food insecure households have fewer constraints on their food intakes than the adults they live with, perhaps because adults compromise their own intakes before allowing children's intakes to be affected (McIntyre et al., 2003). This relationship may not hold true in Aboriginal households due to the severity of food insecurity or other factors related to the Aboriginal experience of food insecurity (Power, 2008; Willows et al., 2009a). In fact, hunger in children has been reported in Inuit communities (Egeland et al., 2010; Lawn & Harvey, 2003).

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Although individuals with food insecurity might be expected to have reduced food intake and therefore a low likelihood of obesity, some research indicates that obesity is paradoxically more prevalent among children who are moderately poor or food insecure (Alaimo et al., 2001; Dubois et al., 2006; Metallinos-Katsaras et al., 2009). This may be because income and food costs are more potent determinants of food selection than considerations of the healthfulness, social desirability, and taste of food (Willows, 2005b). A recent study found that 70% of Inuit preschoolers resided in households rated as food insecure. Despite children skipping meals and going hungry, overweight and obesity were prevalent in children, perhaps due to overall poor diet quality (Egeland et al., 2010). The low cost of high-calorie foods that are easy to overconsume may be one mechanism whereby children who are food insecure become obese (Drewnowski, 2007). (p.314) Creating ecological obesity interventions By adopting an ecological framework to address obesity, Canadian policy makers would look beyond the physiological determinants of obesity in Aboriginal populations to examine the underlying social, cultural, and economic contributors. The Framework for Action on Healthy Body Weight in Children developed by Plotnikoff et al. (2008) describes the key ingredients required to advance knowledge and guide action for the prevention and treatment of childhood obesity. As such, for action on Aboriginal childhood obesity the following are required: 1) surveillance (i.e. What is the problem?), 2) risk factor or condition identification (i.e. What is the cause?), 3) intervention and evaluation (i.e. What works?), and 4) implementation (i.e. How do you do it?). The following recommendations by the First Nations and Inuit Health Committee of The Canadian Paediatric Society (2005) for the prevention of T2D in Aboriginal children would also apply to the development of obesity prevention strategies: ◆ Culturally based and community-run prevention programmes. ◆ Traditional values, including traditional diets, activities, and lifestyles, should be encouraged. Group activities, including those with elders, may be most effective. ◆ Breastfeeding is the most natural component of a traditional diet and should be encouraged as a proven method of reducing obesity in children. ◆ Daily physical activity for at least 60 min to 90 min, as outlined in Canada’s Physical Activity Guide, is recommended for all children. Activities for endurance, flexibility, and strength should be encouraged and one-third of the activity should be of moderate intensity. ◆ Schools, daycares, and Head Start programmes should incorporate at least 30 min of highenergy, daily physical activity for all students, and should incorporate programmes that explain the need for healthy active living and healthy eating into their curriculums. ◆ Schools should be discouraged from selling candy or other sweets for fundraising purposes. ◆ A healthy diet based on Canada’s Food Guide, which incorporates traditional diets, is the desired nutritional goal.

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◆ A boriginal community leaders should provide ample access to safe physical activities within the communities. ◆ Community members must be active role models for the children. ◆ Local stores should be encouraged to stock healthy foods and to place high-caloried ‘junk’ food in less obvious locations in the store. ◆ Passive activities such as watching television, playing video games, and using the computer should be limited to a maximum of 1.5 h to 2 h per day.

Case studies of interventions that used the ecological approach Kahnawake The Kahnawake Schools Diabetes Prevention Project (KSDPP) in the Kanien’kehá:ka (Mohawk) community of Kahnawake, which is close to Montreal Quebec was implemented in 1994. In Kahnawake, the traditional diet (corn, beans, and squash supplemented by foods acquired through fishing, hunting, and gathering) has been replaced by a diet predominantly composed of market foods. There is a high rate of obesity and associated disease in adults in Kahnawake. KSDPP was the first primary prevention programme for T2D in a First Nations community in Canada (Adams, 2005; Montour, 2001). It sought to reduce childhood obesity and the subsequent development of T2D among Kahnawake residents. (p.315) The KSDPP was a well-executed community-based research intervention that adopted an ecological approach to promote healthy weights (Adams, 2005; Bissetet al., 2004; Paradis et al., 2005). The community took a participatory approach ensuring a strong sense of ownership and decision making by community members. The intervention consisted of a combination of social learning theory, the precede–proceed model, Ottawa Charter for Health promotion and traditional learning styles, as well as collaborations within community organizations (Paradis et al., 2005). The project developed a health education curriculum for children reinforced by community activities to encourage healthy food choices and physical activity. At school, a healthy breakfast was offered and at a community level a community garden was developed and healthy eating promoted at community events, through radio shows, and in articles written in the local paper (Paradis et al., 2005). The results from evaluations of the KSDPP reveal that there was no apparent impact on reducing obesity (Adams, 2005; Paradis et al., 2005). Although children were making healthier choices (decreased TV watching and increased physical activity) changes in dietary intake did not occur, and several years after the intervention increases in skinfold thickness and BMI were observed (Jimenez et al., 2003; Paradis et al., 2005;). An explanation is that the community became more obesogenic for children over time with the introduction of satellite television, increased disposable income combined with increasing availabilities of fast-food restaurants in the areas surrounding Kahnawake, and an increased proportion of families in which both parents worked (Paradis et al., 2005).

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Sandy Lake Sandy Lake (Ne gaaw saga’ igan) is a remote Ojibway–Cree community with a population of approximately 2000 located in Ontario in the boreal forest of the Sioux Lookout Zone. In Sandy Lake, the traditional hunting and gathering lifestyle of the inhabitants has been dramatically altered over the last few decades, and this transition in lifestyle likely contributed to the increase in obesity in adults (Harris et al., 1997) and in children (Hanley et al., 2000). Established in 1998, Sandy Lake School Diabetes Prevention Program included culturally relevant lessons for students in the 3rd, 4th, and 5th grades; knowledge and skills development related to healthy eating, physical activity, and diabetes education; a family component informed parents about the healthy eating and physical activity messages their children were learning in school; peers were trained to act as role models; and an environmental component included a healthy school lunch programme as well as a school-wide policy banning high-fat and high-sugar snack food. The intervention was associated with an increase in knowledge about foods low in fat, overall health knowledge, dietary self-efficacy, and with meeting dietary fibre intakes. There was no reduction in obesity in the children as mean BMI and body fat percentage increased during the intervention period (Saksvig et al., 2005). The researchers speculate that the 1-year study period may not have been long enough to show measurable changes in BMI.

Knowledge gaps in our understanding of obesity in Aboriginal children Many limitations and gaps of knowledge have been identified previously (Willows, 2004; 2005a; 2005b; Willows et al., 2009b; Young, 2003), however much still needs to be done. A limitation of the current T2D and obesity research in Aboriginal communities is the exclusion of studying cultural attributes that might foster weight gain, loss, or maintenance (Willows, 2004; Willows et al., 2009b). An understanding of how a culture thinks about obesity is essential for a better understanding of the impact obesity has on psychosocial concerns and weight control behaviours (Davis et al., 2000; Neumark-Sztainer et al., 1997). To develop health promotion strategies for (p.316) obesity prevention in Aboriginal school children it would therefore be important to have an appreciation for children’s body size perceptions, understand where and how children acquire their knowledge of healthy body sizes, and the forms of teachings and activities that would best increase positive lifestyle behavioural changes.

Conclusions There is a range of evidence to suggest that childhood obesity in Canadian Aboriginal populations is a highly prevalent problem that must be addressed to ensure the health of children; however, there are a number of limitations associated with promoting healthy weights in the Aboriginal context. There are no comprehensive national survey data on measured (not self-reported) body weight of Aboriginal children living on-reserve or in remote areas. Although some reports have documented obesity in Aboriginal children to be associated with risk factors for T2D and heart disease, few studies have examined the causes of obesity, and information addressing the social and environmental causes of obesity is limited. Although it is acknowledged that ecological interventions should be developed for Aboriginal children, it is not clear which directions interventions should take (Story et al., 1999). Utilizing an ecological approach, there is a need to address obesity-related problems by focusing on the social determinants of health. There is much room for improvement regarding ecological research in the context of Aboriginal child obesity. References Page 9 of 17

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Raphael, D. (2007) Addressing health inequalities in Canada: little attention, inadequate action, limited success. In A. Pederson, I. Rootman, M. O'Neill, & S. Dupere (Ed.) Health promotion in Canada: critical perspectives 2nd edition, pp. 106–122. Toronto: Canadian Scholars' Press. Richmond, C., Ross, N.A., & Egeland, G.M. (2007) Societal resources and thriving health: a new approach for understanding the health of Indigenous Canadians. American Journal of Public Health 97(10), 1827–1833. Rinderknecht, K. & Smith, C. (2002) Body-image perceptions among urban Native American youth. Obesity Research 10, 315–327. RHS National Team (2007) First nations regional longitudinal health survey (RHS) 2002/03. Results for adults, youth and children living in First Nations communities. Report: Assembly of First Nations/First Nations Information Governance Committee Ottawa, ON. Saksvig, B.I, Gittelsohn, J., Harris, S.B., Hanley, A.J.G., Valente, T.W., & Zinman, B. (2005) A pilot school based healthy eating and physical activity intervention improves diet, food knowledge and self efficacy for native Canadian children. Journal of Nutrition 135, 2392–2398. Shields, M. (2006) Overweight and obesity among children and youth. Health Reports 17, 27–42. Slater, J. (2007) Community food security. Position of dietitians of Canada. . (Accessed 14 September 2009). Story, M., Hauck, F.R., Broussard, B.A., White, L.L., Resnick, M.D., & Blum R.W. (1994) Weight perceptions and weight control practices in American Indian and Alaska Native adolescents. A national survey. Archives of Pediatric and Adolescent Medicine 148, 567–571. Story, M., Evans, M., Fabsitz, R.R., Clay, T.E., Rock, B.H., & Broussard, B. (1999) The epidemic of obesity in American Indian communities and the need for childhood obesity-prevention programs. American Journal of Clinical Nutrition 69(4), 747S–754S. Tait, H. (2008) Aboriginal peoples survey, 2006: Inuit health and social conditions. Catalogue no. 89-637-X — No. 001. Ottawa: Statistics Canada, Social and Aboriginal Statistics Division. Online Access: . (Accessed 26 September 2009). Trifonopoulos, M. (1995) Anthropometry and diet of Mohawk schoolchildren in Kahnawake. Master’s thesis. McGill University, Montreal. Trifonopoulos, M., Kuhnlein, H.V., & Receveur, O. (1998) Analysis of 24-hour recalls of 164 fourth- to sixth-grade Mohawk children in Kahnawake. Journal of the American Dietetic Association 98(7), 814–816. Vallianatos, H., Brennand, E.A., Raine, K., et al. (2008) Cree women speak: intergenerational perspectives on weight gain during pregnancy and weight loss after pregnancy. Journal of Aboriginal Health 4(1), 6–14.

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Wilkinson, R. & Marmot, M. (Ed.) (2003) Social determinants of health. The solid facts. 2nd edition. Geneva: WHO. Wilkins, R., Uppal, S., Finès, P., Senécal, S., Guimond, É., & Dion, R. (2008) Life expectancy in the Inuit inhabited areas of Canada, 1989 to 2003. Health Reports 19(1), 7–19. Willows, N.D. (2004) Developing culturally appropriate weight-control strategies. Canadian Journal of Diabetes 28(4), 358–359. Willows, N.D. (2005a) Overweight in aboriginal children: prevalence, implications and solutions. Journal of Aboriginal Health 2, 76–85. Willows, N.D. (2005b) Determinants of healthy eating in aboriginal peoples in Canada: the current state of knowledge and research gaps. Canadian Journal of Public Health 96, S32–S36. Willows, N.D., Iserhoff, R., Napash, L., Leclerc, L., & Verrall, T. (2005) Anxiety about food supply in Cree women with infants in Quebec. International Journal of Circumpolar Health 64, 59–68. Willows, N.D., Johnson, M., & Ball G.D.C. (2007) Prevalence estimates of overweight and obesity in Cree preschool children in northern Quebec according to international and US reference criteria. American Journal of Public Health 97(2), 311–316. Willows, N.D., Veugelers, P., Raine, K., & Kuhle, S. (2009a) Prevalence and sociodemographic risk factors related to household food security in aboriginal peoples in Canada. Public Health Nutrition 12(8), 1150–1156. Willows, N.D., Marshall, D., Raine, K., & Ridley, D.C. (2009b) Diabetes awareness and body size perceptions of Cree schoolchildren. Health Education Research 26(4), 1051–1058. World Health Organization (1986) The Ottawa charter for health promotion. Ottawa: Health and Welfare Canada. Retrieved from: . Young, T.K., Reading, J., Elias, B., & O’Neil, J.D. (2000) Type-2 diabetes in Canada’s First Nations: Status of an epidemic in progress. Canadian Medical Association Journal 163, 561–566. Young, T.K. (2003) Review of research on aboriginal populations in Canada: relevance to their health needs. BMJ 327, 419–422. Zorzi, A., Wahi, G., Macnab, A.J., & Panagiotopoulos, C. (2009) Prevalence of impaired glucose tolerance and the components of metabolic syndrome in Canadian Tsimshian Nation youth. Canadian Journal of Rural Medicine 14(2), 61–67.

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Environment and policy interventions to prevent obesity in children

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Environment and policy interventions to prevent obesity in children Dianne S. Ward Amy V. Ries Rachel Tabak

DOI:10.1093/acprof:oso/9780199572915.003.0028

Abstract and Keywords This chapter presents environmental and policy interventions which have demonstrated an impact on a measure of body weight or been successful in improving eating or physical activity behaviours among children aged 2 to 18. It presents the types of macro- and microenvironmental and policy interventions that have been conducted, what areas seem promising, and where major gaps exist. The chapter discusses various interventions to prevent childhood obesity from around the world, community approaches, and approaches that suggest environmental changes including physics, economic, and political environments. The chapter also puts forward a discussion of interventions that target policy changes such as policy that address laws and regulations as well as formal and informal rules.

Keywords: physical activity, eating, policy interventions, community approaches, environmental changes, policy changes

Chapter summary The purpose of this chapter is to present environmental and policy interventions which have demonstrated an impact on a measure of body weight or been successful in improving eating or physical activity behaviours among children aged 2 to 18. It is beyond the scope of this chapter to present a systematic review of this topic or to evaluate the quality of evidence presented. The goal is to educate the reader about the types of macro- and micro-environment and policy interventions that have been conducted, what areas seem promising, and where major gaps exist. We discuss various interventions to prevent childhood obesity from around the world, community approaches and approaches that suggest environmental changes including the

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physical, economic, and political environments. We also present a discussion of interventions that target policy changes such as policy that addresses laws and regulations as well as formal and informal rules. The successful multi-component interventions that are discussed in this chapter represent viable starting points to address childhood obesity prevention.

Background The precipitous rise in obesity worldwide requires population-based approaches to effectively combat this serious, debilitating, and costly health problem. Children are the priority group for population approaches to obesity because of the difficulties in treating obesity in adults. Thus far, however, interventions to prevent childhood obesity have been minimally successful (Brown & Summerbell, 2009; Doak et al., 2006; Flodmark et al., 2006; Kamath et al., 2008; Sharma, 2006; Summerbell et al., 2005; van Sluijs et al., 2007). Community approaches, especially those that include environmental and policy changes, appear to be warranted (French, 2005; Kirk et al., 2009; Swinburn & Egger, 2002); and they are one of the most frequently proposed strategies for the prevention of childhood obesity (Kirk et al., 2009). Although environmental and policy interventions into childhood obesity are limited, particularly due to a lack of longitudinal research and other methodological limitations, there is a general consensus that addressing environmental factors and policy is critical. Defining environment and policy In the health literature, the term environment is defined in many ways, but often refers very broadly to the space surrounding a person and includes elaboration in relation to obesity (Sallis & Owen, 2002; Swinburn et al., 1999). The environment is conceptualized as consisting of two ‘sizes’: the microenvironment that refers to settings that individuals interact with, such as homes (p.322) and schools, and the macro-environment which refers to sectors that influence micro-environments, such as government, education, and the food industry. Swinburn et al. further describe four ‘types’ of environments, including the physical environment which refers to ‘what is available’ (i.e., stores, recreational facilities, information on diet), the economic environment which refers to costs, the political environment which refers to laws, regulations, and formal and informal policies, and the sociocultural environment which refers to attitudes, beliefs, and values (Swinburn et al., 1999). For intervention approaches, environmental interventions can be conceptualized as interventions that do not require the individual to select himself into the intervention (French & Stables, 2003). Environmental approaches may be more effective than individual-level behaviour change strategies because they do not require a voluntary effort by individual participants (Stokols, 1996). Furthermore, environmental approaches may reach larger audiences (Wechsler et al., 2000). For example, using the school environment to promote physical activity and healthy eating can reach populations that are harder to reach with individual-level strategies (Galbally, 1997), and it can be more sustainable (Swinburn et al., 1999) and cost-effective (Schmid et al., 1995; Swinburn et al., 1999). Policies may be defined as ‘laws, regulations, formal and informal rules and understandings that are adopted on a collective basis to guide individual and collective behavior’ (Wallack, 1990). It is important to note that the differences between policies and environmental changes are not

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always clear, as policies can be used to implement environmental change. For example, a community might pass a regulation (policy) that requires new housing developments to have sidewalks, and, as a result, residents of this neighbourhood begin to walk more than they had previously because the sidewalks (environment) connect to destinations such as stores or parks. Thus, a policy created an environmental intervention and a behaviour change. For this chapter, we have chosen to use the definition of environment put forth by Swinburn et al. because it applies specifically to the problem of obesity and is often used when addressing childhood obesity. We have, however, chosen to narrow our focus to only three of the four ‘types’ of environments, including the physical, economic, and political environments. We will not address the socio-cultural environment because measuring and intervening into this aspect of the environment is difficult and complex (Swinburn et al., 1999). Also, interventions addressing this aspect of the environment are limited and not well evaluated. With regard to the political environment or policy, we have chosen to use a general definition of policy that addresses laws and regulations as well as formal and informal rules.

Interventions to change the food environment Free fruit and vegetable programme A number of studies have observed that offering free fruit and vegetable provisions to school children has short-term effectiveness and/or modest results (Bere et al., 2005; Bere et al., 2007; Davis et al., 2009; Fogarty et al., 2007; Ransley et al., 2007; Van Cauwenberghe et al., 2010; Wells & Nelson, 2005). Most of these studies have been conducted in Europe and are part of a national initiative to increase fruit and vegetable consumption (de Sa & Lock, 2008; Van Cauwenberghe et al., 2010). Only one study (Bere et al., 2005) showed a sustained effect on children’s fruit and vegetable intake (Bere et al., 2007). In general, when these programmes end, intake returns to pre-intervention levels. It probably will be necessary to conduct costeffectiveness studies to assess the potential of these programmes to contribute to improvements in future health status (de Sa & Lock, 2008). (p.323) Modifying food offerings Eating breakfast has been associated with lower obesity levels in children and adolescents (Gleason & Dodd, 2009; Szajewska & Ruszczynski, 2010; Timlin et al., 2008). A limited number of studies have evaluated the impact of breakfast provision on weight status in children and youth. In a pilot study conducted in Norway, one class of 10th grade students was offered a free breakfast for 4 months, whereas a second class served as control (Ask et al., 2006). Healthier dietary profiles and reduced weight gain were observed for students in the intervention group. In a larger, cluster randomized, controlled trial conducted in low-income areas across England, Shemilt and colleagues found mixed results: some positive changes in student behaviour (school attendance, eating fruits and vegetables), but difficulties in implementation (Shemilt et al., 2004). In addition to breakfast offerings, interventions have been developed to modify the a la carte offerings within schools. Significant changes in ounces of water, sweetened beverages, and regular chips sold, as well as significant reduction in kilocalorie density per item sold were observed in a non-randomized study in six middle schools in three states (Hartstein et al., 2008).

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In a similar vein, Schwartz and colleagues conducted a quasi-experimental study over 2 years in three middle schools (versus three comparison schools) to assess the impact of implementing snack guidelines for foods sold at school during the school day (cafeteria a la carte, vending, and fundraisers) (Schwartz et al., 2009). Sweetened beverage intake increased in the comparison schools, but decreased in intervention schools during Year Two. Similarly, water and 100% fruit juice increased in intervention schools in Year Two but not in comparison schools. More healthy snacks were consumed by intervention students in the second year of the intervention, whereas comparison schools remained the same. Data suggest that modifications in snack offerings in schools are feasible and result in encouraging changes to children’s snack intake. Modifying food pricing French and colleagues conducted two studies to assess the impact of lowered prices of foods with higher nutrition value. The CHIPS study (Changing Individuals’ Purchase of Snacks) investigated price reductions and point-of-purchase promotion on the sale of snacks at 12 secondary schools in Minnesota (French et al., 2001). Prices of low-fat snack foods in vending machines in each of the schools were reduced by 10%, 25%, and 50% and sales in these items increased by 9%, 39%, and 93%, respectively. Where there were 25% and 50% price reductions, low-fat snack sales volume increased significantly. A second study looked at the impact of reducing prices for fresh fruit and vegetables purchased at two high school cafeterias (French et al., 1997). Prices for fresh fruit and baby carrots were reduced by 50%, and fruit sales increased from 14 to 63 items per week. Baby carrot sales doubled from 37 to 77 packets per week. When the sale period ended, sales returned to baseline levels. School gardens Efforts to increase the availability of fresh, local products, especially fruits and vegetables, have led to the establishment of farmer’s markets and community gardens in many neighbourhoods (Twiss et al., 2003; Wakefield et al., 2007). Few studies have attempted to assess the impact of this change to the school environment, but two reviews recently examined the impact of school gardens (Ozer, 2007; Robinson-O'Brien et al., 2009). Most of the studies reviewed were small in size, non-randomized, and had limited outcome measures. In spite of the modest results to date, school gardens may increase fruit and vegetable intake by affecting children’s willingness to (p. 324) try new foods and increasing their preferences for fruits and vegetables (RobinsonO'Brien et al., 2009). However, additional studies are needed in this area (Ozer, 2007; RobinsonO'Brien et al., 2009).

Interventions to change the physical activity environment Additional activity opportunities Availability and accessibility of opportunities can increase children’s physical activity and energy expenditure, and possibly affect body weight. Most interventions that investigate the benefit of additional activity opportunities have done so in multi-component programmes (see later). However, one area that has been studied separately is activity breaks during academic classes. The Take 10! Program is a series of classroom activities appropriate for use either as a break from class work or as an active reinforcement for class content (e.g., math or language studies) that has resulted in measurable increases in physical activity across three different grades (1st, 3nd, and 5th). Another programme, ‘Energizers’, was tested by Mahar and

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colleagues (Mahar et al., 2006), who found that students in the intervention group took significantly more in-school steps than control-group students. Enhanced equipment or physical facilities Within schools, several environmental interventions have been enacted to improve physical activity among students. A number have focused on redesign of playgrounds, specifically playground marking, and a few have considered the importance of enhanced equipment. In a small study of movable play equipment in one preschool, Hannon and Brown found that children’s physical activity over 5 days increased (over the preceding week) when the children were led through a daily obstacle course with study-provided equipment (Hannon & Brown, 2008). However, it is not known whether these changes resulted from the new equipment or the novel configuration (the obstacle course) that occurred daily. A number of interventions have added colourful markings to elementary school playgrounds, and then assessed changes in children’s physical activity (Cardon et al., 2009; Loucaides et al., 2009; Ridgers et al., 2007; Stratton & Mullan, 2005; Willenberg et al., 2009). Most of these are small studies with short implementation periods. Their positive results suggest that modifications to play areas may enhance children’s activity. However, more work is needed, perhaps in combination with other environmental modifications such as provision of play equipment. Obtaining access to existing play facilities can be a barrier to children’s activity. Researchers tested the effect of providing a safe play space on physical activity levels of inner-city children (Farley et al., 2007). In one of two matched neighbourhoods, a schoolyard was opened for use, and attendants provided supervision. Play yard use was assessed over 2 years by direct observation. Activity levels in the intervention neighbourhood were 84% higher than in the control neighbourhood, with reported decreases in TV, movie, DVD, and other video use on the weekends. More research is needed to understand the benefits of improved access to facilities along with supervision for active play.

Multi-component interventions at schools In addition to single environment interventions, multi-component interventions added an environmental component to a larger intervention, although they did not necessarily evaluate the environmental component separately. (p.325) Nutrition-only interventions Lytle and colleagues conducted a randomized controlled trial (RCT) in 16 Minnesota middle schools to study the effects of an educational and environmental intervention. The TEENS study was designed to increase the availability of fruits, vegetables, and lower fat foods in homes and schools (Lytle et al., 2006). In addition to educational modules and family newsletters, this intervention made changes to the school food environment to increase the number of healthful a la carte and school lunch line options. Results showed that intervention schools offered and sold a higher proportion of healthier foods a la carte; no effects were seen for fruit and vegetables sales as part of the regular lunch meal pattern. A comprehensive policy intervention conducted in Philadelphia area schools (Foster et al., 2008) included a local community-based food organization and a community task force to implement healthy eating guidelines suggested by the Centers for Disease Control and Prevention (Centers

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for Disease Control and Prevention, 1996). This randomized control trial was implemented in diverse schools and targeted policy and environment changes to the food environment, along with nutrition education programmes. Although some consideration of physical activity in the schools was included, it was a secondary focus and not prominent in the intervention. After 2 years, BMI-z scores improved, demonstrating that positive changes in obesity can occur in schools with high enrollments of at-risk children by using community planning and implementing school-level policy changes. Physical activity-only interventions An example of a multi-component physical activity intervention developed for middle school girls is the Trial of Activity in Adolescent Girls, or TAAG. This large, multi-centre RCT involved 36 middle schools from six different states. In its implementation phase, TAAG focused on modifying physical education and health education to promote physical activity and to encourage community partners to increase activity offerings during and after school. In its maintenance phase, Program Champions were employed to direct the intervention and continue to coordinate community support (Webber et al., 2008). As a result of the Program Championdirected intervention, girls in intervention schools were more physically active than girls in control schools (about 80 kcal per week). The Lifestyle Education for Activity Program, or LEAP, successfully used the Program Champion model, along with a school-wide planning team, to implement components of the Coordinated School Health Program (Marx & Wooley, 1998). Components included the physical education and health education programmes, staff wellness programmes, school environment, and community and families activities (Pate et al., 2005; Ward et al., 2006). This programme resulted in higher prevalence of physical activity in girls in the intervention group compared to those in control group; however, there was no effect on BMI. JUMP-in was a comprehensive, theory-based intervention conducted in Amsterdam that included environmental changes designed to increase physical activity in early adolescent students (Jurg et al., 2006). Along with educational activities conducted during school, additional school sports activities, parent information, and periodic parent–child activities at local sports clubs were provided. JUMP-in increased physical activity participation; intervention children in Grade 6 maintained their pre-intervention activity levels, whereas activity levels of children in the control group decreased. ICAPS (Intervention Centered on Adolescents’ Physical activity and Sedentary behaviour) was a multi-component intervention implemented in eight middle schools in France (Simon et al., 2004; Simon et al., 2006). The intervention aimed to change knowledge, attitudes, and motivation, (p.326) to increase social support, and to provide environmental, structural, and institutional support for physical activity. Environmental and policy changes included providing new opportunities for physical activity during and after school, and requesting that policy makers provide a supportive environment for physical activity. ICAPS resulted in a significant increase in youth engaged in supervised physical activity outside of physical education, and a signification reduction in time spent engaged in sedentary activities.

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Nutrition- and physical activity-related interventions An early multi-component intervention trial to address diet and physical activity was the CATCH (Child and Adolescent Trial for Cardiovascular Health) trial (Luepker et al., 1996). Along with educational programming and parent education, CATCH included a comprehensive component to improve the nutritional quality of meals provided through the US School Breakfast and Lunch Programs. Although no change in BMI was observed, significant alteration occurred in meals (lower fat and sodium content) following the intervention. New Zealand’s APPLE intervention was designed to increase physical activity and intake of fruit and vegetables, and reduce the intake of sugary drinks in elementary students in one intervention community with four schools, compared to a comparison community with three schools (Taylor et al., 2008; Taylor et al., 2007). The 2-year intervention used Community Activity Coordinators at each school to increase non-curricular activity at recess, lunchtime, and after school. In addition to educational sessions, other activities included classroom activity breaks, increased availability of sports equipment for free play, increased filtered water, and free fruit. Children in intervention schools had increased physical activity, less sedentary time, and lower BMI- Z scores compared to control schools. In Belgium, Haerens and colleagues implemented a randomized controlled trial in middle schools that involved environmental changes, personal computer-tailored feedback, and parental involvement (Haerens et al., 2006). Intervention activities included increased activity time (inclass, lunch, after school) and provision of sports equipment to each school for non-instructional use. Schools also were asked to provide fruit and water for free or reduced prices. BMI and BMI z-scores increased less in girls in intervention schools (with parental support) than in the control or intervention-alone group. Also, positive intervention effects were observed for physical activity in boys and girls and for fat intake in girls (Haerens et al., 2006). Another multi-component RCT intervention that included a significant environmental component was the Middle School Physical Activity and Nutrition Study or M-SPAN. Middle schools in California received new physical activity equipment, provided more teacher supervision and additional activities, and made changes to the school food services (lower-fat vendor items promoted with social marketing). Again, a significant interaction for gender was seen in these results: improvements in BMI and physical activity were observed, but only for boys. Guidelines for school programmes to promote healthy eating and physical activity have been established by such groups as the US Centers for Disease Control and Prevention (Coordinated School Health Program, 2010) and the World Health Organization (Global School Health Initiative, 2010). These programmes encourage coordination among all facets of the school programme in order to impact child health. Few evaluations of the impact of these all-school approaches on preventing obesity have been conducted. A study from Nova Scotia compared differences in prevalence of overweight and obesity in schools that reported either: no nutrition programme, a nutrition programme, or participation in a coordinating school health programme (Veugelers & Fitzgerald, 2005). Risk of overweight/obesity was significantly less in the schools participating in a coordinated programme, even when controlling for a number of school level factors, including income, education, and geographic area.

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(p.327) A similar programme was conducted in British Columbia. Action Schools! BC – Healthy Eating was a policy intervention to change offerings and teacher practices to promote fruit and vegetable consumption (Day et al., 2008; Naylor et al., 2008; Reed et al., 2008). School health teams (called Action Teams) were used to affect policies and practices at the school level across six areas, including school environment, physical education, extra-curricular activities, school spirit, family and community involvement, and classroom activity breaks. The programme was implemented in five schools, and the results compared with matched controls over a 16-month period. Fruit, fruit/vegetable servings, and the number of fruits/vegetables ‘tried’ increased in intervention schools, as did physical fitness. Physical activity (step counts) increased in boys only. The authors note that although many positive changes occurred, implementation was uneven and often challenging and additional studies are needed (Day et al., 2008). Multi-component neighbourhood or community interventions Few interventions targeting childcare exist and even fewer addressed the comprehensive aspects of healthy weight environment (Hesketh & Campbell, 2010). One of the few programmes to target childcare is the NAP SACC programme – Nutrition and Physical Activity SelfAssessment for Child Care (Ward et al., 2008). This programme uses staff self-assessment, followed by selection of target areas for change. Although the NAP SACC evaluation study did not measure child behaviour, the intervention resulted in measurable changes in the nutrition and physical activity environments. Although the changes observed in this randomized control trial were modest, NAP SACC has good acceptability by centre staffs and has been found easy to disseminate (Drummond et al., 2009). Food provisions at local stores may impact what children consume and create increased risks for obesity. In the first study of neighbourhood food stores and children’s dietary intake, Gittelsohn and colleagues implemented a store-level intervention in Hawaii (Gittelsohn et al., 2010). Five food stores in two communities were selected as implementation sites and two others in similar areas served as control sites. The intervention targeted changing to healthier beverages, healthier children’s snacks, healthier condiments (e.g., ‘lite’ mayonnaise), and healthier meals. Stores were also provided point-of-purchase educational displays and promotions. Although parents were the targets of the intervention, as they generally control home food purchases, children significantly increased their Healthy Eating Index scores after the nearly year-long intervention. Shape-Up Sommerville is an example of an orchestrated community intervention to prevent weight gain in young children in grades 1–3 (Economos et al., 2007). This non-randomized controlled trial was conducted in an urban area and involved three culturally diverse cities from one state. A community participation process was used to address all aspects of the children’s school day, including before school (breakfast programme, active school travel), during school (staff development, food service, curriculum, enhanced recess, wellness policies), afterschool (programmes, school travel), home (parent education, events), and community (advisory council, champions, wellness campaigns, and more). Engagement of multiple environments to make policy changes, coupled with education and promotion, were effective in changing BMI z-scores in the intervention communities (compared with control communities). Albeit challenging, community interventions hold the promise of rich rewards.

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Healthy Living Cambridge Kids was a community intervention in Cambridge, Massachusetts, that used Community-based Participatory Research (CBPR) methods (Chomitz et al., 2010). This single group study was conducted over 3 years and was a joint project of a local obesity task force, a health institute, and department of public health. Engaging such community organizations as city officials, school personnel, health professionals, and gardening advocates allowed for activation (p.328) of multiple channels of influence. Results were encouraging: obesity among all race/ethnicity groups declined, although the changes were modest. This approach shows promise for creating sustainable changes in the environment that will affect children’s energy balance.

Conclusions There is universal agreement that researchers must do more to prevent childhood obesity, but international efforts to date have had limited success. In this chapter, we were limited in our ability to conduct a systematic review of environmental and policy interventions because of the broad scope of the topic and the small number of relevant studies within it. However, from the studies we examined, it appears that study quality (lack of control groups, non-random designs, brief intervention period) in nutrition- and physical activity-targeted interventions has been modest at best. Some of the multi-component studies were RCTs, but these studies included other strategies, such as educational programming and promotions, and the environmental component was not evaluated separately. Previous reviews have noted the limited numbers of environmental and policy interventions in the literature and suggest more studies are needed. In this chapter, we presented an array of different environmental approaches including improving access to healthy foods and increasing physical activity opportunities. These are important and necessary modifications of environment and/or policy. However, it is through multi-component interventions that these modifications might be most effective. Addressing only one issue, such as how to provide more fruits and vegetables or more healthy snacks, might solve one barrier, but getting children to eat more healthy foods and having an impact on child weight are issues that still need solutions. We presented several examples of multi-component interventions that showed positive effects on children’s weight, diet, and/or physical activity levels. These interventions ranged from decreasing the fat content of school lunch and improving the physical education programme to mobilizing community partners to address obesity prevention of children in neighbourhoods. Most successful interventions were implemented in school settings, so we can continue to use that common approach. These studies demonstrate that only healthy foods should be provided at schools, and children deserve access to opportunities, equipment, and spaces for activity. Policy interventions that affect environmental changes seem to make these enhancements successful. In the United States, Canada, and Europe, the concept of coordinated school health programmes has been part of a number of successful school-based, multi-component interventions. School planning teams, wellness councils, programme champions, and community outreach are common themes in these successful efforts. Ideally, we would prefer both ‘top down’ and ‘bottom up’ approaches that include committed policy makers and energetic community action teams, but these rarely occur synchronously (Swinburn & de Silva-Sanigorski, 2010).

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Indeed, successful interventions for obesity prevention require a combination of approaches – educational, behavioural, and environmental/policy changes along with a change in the culture of how we approach food, physical activity, health, and economics (Huang & Story, 2010). Thus, though the need to prevent obesity in children remains great, the successful multi-component interventions that have been discussed in this chapter represent viable starting points to address obesity prevention. Although we should continue to evaluate individual environmental strategies, we should look for effective strategies that can be integrated into multi-component approaches. Moreover, instead of developing new interventions, we should look to successful, existing intervention models or approaches that can be easily replicated, adapted, or developed further as a starting point. References Bibliography references: Ask, A.S., Hernes, S., Aarek, I., Johannessen, G., & Haugen, M. (2006) Changes in dietary pattern in 15 year old adolescents following a 4 month dietary intervention with school breakfast – a pilot study. Nutrition Journal 5, 33. Bere, E., Veierod, M.B., & Klepp, K.I. (2005) The Norwegian School Fruit Programme: evaluating paid vs. no-cost subscriptions. Preventive Medicine 41(2), 463–470. Bere, E., Veierod, M.B., Skare, O., & Klepp, K.I. (2007) Free School Fruit – sustained effect three years later. International Journal of Behavioral Nutrition and Physical Activity 4, 5. Brown, T. & Summerbell, C. (2009) Systematic review of school-based interventions that focus on changing dietary intake and physical activity levels to prevent childhood obesity: an update to the obesity guidance produced by the National Institute for Health and Clinical Excellence. Obesity Review 10(1), 110–141. Cardon, G., Labarque, V., Smits, D., & Bourdeaudhuij, I.D. (2009). Promoting physical activity at the pre-school playground: the effects of providing markings and play equipment. Preventive Medicine 48(4), 335–340. Centers for Disease Control and Prevention (1996) Guidelines for school health programs to promote lifelong healthy eating. MMWR Recommendations and Reports 45(RR-9), 1–41. Chomitz, V.R., McGowan, R.J., Wendel, J.M., et al. (2010) Healthy living Cambridge kids: a community-based participatory effort to promote healthy weight and fitness. Obesity (Silver Spring) 18(n1s), S45–S53. Coordinated School Health Program (2010) US centers for disease control and prevention. Retrieved January 28, 2010, from . Davis, E.M., Cullen, K.W., Watson, K.B., Konarik, M., & Radcliffe, J. (2009) A fresh fruit and vegetable program improves high school students' consumption of fresh produce. Journal of the American Dietetic Association 109(7), 1227–1231.

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Galbally, R.L. (1997) Health-promoting environments: who will miss out? Australian and New Zealand Journal of Public Health 21(4 Spec No), 429–430. Gittelsohn, J., Vijayadeva, V., Davison, N., et al. (2010) A food store intervention trial improves caregiver psychosocial factors and children's dietary intake in Hawaii. Obesity (Silver Spring) 18(n1s), S84–S90. Gleason, P.M. & Dodd, A.H. (2009) School breakfast program but not school lunch program participation is associated with lower body mass index. Journal of the American Dietetics Association 109 (2 Suppl.), S118–S128. Global School Health Initiative (2010) World Health Organization Retrieved January 30, 2010, from . Haerens, L., Deforche, B., Maes, L., Cardon, G., Stevens, V., & De Bourdeaudhuij, I. (2006a) Evaluation of a 2-year physical activity and healthy eating intervention in middle school children. Health Education Research 21(6), 911–921. Haerens, L., Deforche, B., Maes, L., Stevens, V., Cardon, G., & De Bourdeaudhuij, I. (2006b) Body mass effects of a physical activity and healthy food intervention in middle schools. Obesity (Silver Spring) 14(5), 847–854. Hannon, J.C. & Brown, B.B. (2008) Increasing preschoolers’ physical activity intensities: an activity-friendly preschool playground intervention. Preventive Medicine 46(6), 532–536. Hartstein, J., Cullen, K.W., Reynolds, K.D., Harrell, J., Resnicow, K., & Kennel, P. (2008) Impact of portion-size control for school a la carte items: changes in kilocalories and macronutrients purchased by middle school students. Journal of the American Dietetics Association 108(1), 140– 144. Hesketh, K.D. & Campbell, K.J. (2010) Interventions to prevent obesity in 0–5 year olds: an updated systematic review of the literature. Obesity (Silver Spring) 18(n1s), S27–S35. Huang, T.T. & Story, M.T. (2010) A journey just started: renewing efforts to address childhood obesity. Obesity (Silver Spring) 18(n1s), S1–S3. Jurg, M.E., Kremers, S.P., Candel, M.J., Van der Wal, M.F., & De Meij, J.S. (2006) A controlled trial of a school-based environmental intervention to improve physical activity in Dutch children: JUMP-in, kids in motion. Health Promotion International 21(4), 320–330. Kamath, C.C., Vickers, K.S., Ehrlich, A., et al. (2008) Clinical review: behavioral interventions to prevent childhood obesity: a systematic review and metaanalyses of randomized trials. The Journal of Clinical Endocrinology and Metabolism 93(12), 4606–4615. Kirk, S.F., Penney, T.L., & McHugh, T.L. (2009) Characterizing the obesogenic environment: the state of the evidence with directions for future research. Obesity Reviews.

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Individual and environmental interventions to prevent obesity in African American children and adolescents

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Individual and environmental interventions to prevent obesity in African American children and adolescents Portia Jackson Jammie Hopkins Toni Yancey

DOI:10.1093/acprof:oso/9780199572915.003.0029

Abstract and Keywords African-American children and adolescents are at high risk for obesity, physical inactivity, poor nutrition, and related co-morbidities. According to data from the National Health and Nutrition Examination Survey (NHANES) III (1988–94) and NHANES 2003–4, the prevalence of obesity among African-American adolescents nearly doubled during those two decades, among the highest increases of any ethnic group. There are gender differences in obesity, weight gain and fat accumulation with sexual maturation, with rates of growth in obesity 20% higher among girls than boys. The well-documented decline in physical activity during adolescence is also more striking in girls than boys, and in black girls than white girls — in one study, a 100% vs 64% decrease, respectively, between ages 9 and 18 years. This chapter discusses trends in these variables as well as the influence of the physical environment, body image, and outcomes from various interventions among African-American children.

Keywords: children, intervention, eating, health promotion, physical activity, African American, race, culture, USA

Chapter summary African-American children and adolescents are at high risk for obesity, physical inactivity, poor nutrition, and related comorbidities. According to data from the National Health and Nutrition Examination Survey (NHANES) III (1988–1994) and NHANES 2003–2004, the prevalence of obesity among African-American adolescents nearly doubled during those two decades, among the highest increases of any ethnic group. There are gender differences in obesity, weight gain and fat accumulation with sexual maturation, with rates of growth in obesity 20% higher among

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girls than boys. The well-documented decline in physical activity during adolescence is also more striking in girls than boys, and in black girls than white girls – in one study, a 100% versus 64% decrease, respectively, between ages 9 and 18. Trends in these variables will be discussed in this chapter, as well as the influence of the physical environment, body image, and outcomes from various interventions among African-American children.

Introduction Figure 29.1 illustrates the growth in childhood obesity disparities from 1988–94 to 2003–04 (NCHS, 2010). The large increases in obesity among non-Hispanic black girls and boys is noteworthy, as is the very high prevalence among the girls. The physical environment contributes substantively to nutrient-poor food choices, inadequate physical activity, and sedentary behaviour, and low-income and ethnic minority communities bear the brunt of the environmental assault (Hill & Peters, 1998; Nelson et al., 2006). Recent studies have found that blacks were more likely than whites to live in less affluent neighbourhoods that had a higher density of fast food restaurants, a lower density of supermarkets, and a higher density of advertising for fast foods, sugary beverages, and sedentary activities (i.e. television shows, films, automobiles, and video games (Morland et al., 2002b; Yancey et al., 2009b). Supermarket density, in particular, has been linked to fruit and vegetable consumption among African Americans (Morland et al., 2002a). Schools in low-income communities may also offer fewer healthy options. African-American 8th, 10th, and 12th graders were less likely than whites to report that their schools offered healthy a la carte or vending machine snacks such as fruits and vegetables, or low-fat food items (Delva et al., 2007). (p.334) Similarly, fewer opportunities are available for energy expenditure. A recent study found that between 2004 and 2007, there was a sharp decrease in students reporting that their schools required physical activity for their grade as they ascended to higher grade levels, from 88% in the 8th grade to 20% in the 12th grade, with 92% of students surveyed taking physical education (PE) in the 8th grade, compared to 64% in the 10th grade, and 34% in the 12th grade (O'Malley et al., 2009). Students in low-resource school environments are less active during PE and recess periods, due to lack of PE specialists and overcrowded classes, understaffed and overcrowded playgrounds, and insufficient or poorly maintained

Fig. 29.1 Growth in childhood obesity disparities: 1988–94 (bottom) to 2003–04 (top).

equipment and facilities (UCLA Center to Eliminate Health Disparities, 2007; Samuels et al., 2010). Many low-income schools do not have working water fountains (Muckelbauer et al., 2009). People from low-income backgrounds often characterize their neighbourhoods as unsafe, or unsuitable for physical activity, including walking or biking to school (Casagrande et al.,

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2009; Ward-Begnoche & Thompson, 2008). As a result, children, particularly girls and young women, are often encouraged to stay indoors (Cecil-Karb & Grogan-Kaylor, 2009). This segues into the role of the socio-cultural environment in poor nutrition, physical inactivity, and obesity. Formative interviews conducted among African-American girls and their caregivers revealed that the girls preferred sedentary behaviour, such as watching television, to physical activity, and their caregivers perceived television viewing as an activity that helped keep their daughters safe (Gordon-Larsen et al., 2004). California Health Interview Survey data on adolescent television viewing revealed that half of white males and 60% of white females watched 2 or fewer hours per day, whereas only one-third of African Americans' viewing was at this recommended level (Yancey et al., 2003). Children's television, especially programming targeting young African Americans, is saturated with commercial advertising for nutrient-poor foods such as sugar-sweetened cereals (Institute of Medicine, 2004; Outley & Taddese, 2006). Links have been substantiated between screen time and eating habits, e.g., sugar-sweetened beverage consumption (Barr-Anderson et al., 2009; Kremers et al., 2007). In fact, the only successful obesity-related litigation to date against the food industry involved the settlement of a class action suit against General Mills for exploitative advertising aimed at ethnic minority preschoolers (Hinkle, 1997). A more than four-fold excess in overweight/obesity rates has been documented among black audience prime time actors compared with general audience prime time actors (Tirodkar & Jain, 2003). (p.335) Individually targeted and environmental-level approaches are needed in order to realize the goal of preventing obesity in African-American children and adolescents. Just as there are many challenges to promoting healthy eating and physical activity, there are also many opportunities for intervention. These opportunities are particularly likely to present themselves when researchers and practitioners elect to use a non-traditional lens, identifying cultural assets and facilitators rather than solely deficits and barriers (Day, 2006; GordonLarsen et al., 2004; Van Duyn et al., 2007; Yancey, 2010; Yancey et al., 2006a). For example, dance, ethnic foods, and sports are widely embraced among African Americans, American Indians, Latinos, and other ethnic minority groups, as are collectivist values that place uplifting family and community over personal goals and ambition. Organizational infrastructure and commitment from key leadership is crucial to achieving substantive improvements in physical activity and nutrition, and to sustaining changes made during an intervention (Yancey et al., 2007; Yancey, 2009). Studies conducted with African Americans residing in low-income neighbourhoods have suggested that structured programming at the environmental level may improve access to safe facilities, increase social support, and foster feelings of connectedness at the community level, assisting individuals in building healthy lifestyles (Frenn et al., 2005; Griffin et al., 2008; Lees et al., 2007).

Body image Mainstream messages promoting healthy eating and physical activity are frequently tied to weight loss, presupposing universal standards for overweight self-perception and motivation to be thin that are much less common among African Americans and other people of colour (Yancey et al., 2006b). For example, an earlier study found that obese African-American girls in Philadelphia were more likely to consider their overweight body size as normal or ideal (Gordon-

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Larsen, 2001), and a recent study among low-income African-American adolescents in Chicago found that one-third of the sample underestimated their own body weight, and that boys were less likely to express dissatisfaction with their weight than girls (Wang et al., 2009). Nsiah-Kumi et al. (2009) found that parents of African-American children were less likely to perceive them as being at risk for obesity-related diseases than parents of children in other ethnic groups (NsiahKumi et al., 2009). Recent studies have shown that parental obesity is a risk factor for obesity in children beyond genetic pre-disposition (Crossman et al., 2006; Institute of Medicine, 2006). However, another study of African-American girls aged 6–9 and their primary caregivers in North Carolina found that girls perceived being fat as unhealthy, caregivers served as role models for body image, ability to wear fashionable clothes was related to body size, and most perceived their current body size as unhealthy compared to their ideal size (Katz et al., 2004). This highlights the crucial role of parents and other adult role models in obesity prevention, as micro-social norms, behaviours, and perceptions often shape the physical activity and eating habits of children and adolescents (Trost et al., 2003; Yancey et al., 2010). A recent study of parental beliefs found that parents exhibit higher self-efficacy for influencing their child’s health behaviours if they believed in parental modelling, and if their child was under the age of 12, lending further support to the strategic involvement of parents in interventions for AfricanAmerican youth (Nsiah-Kumi et al., 2009).

Individually targeted interventions Ten interventions were targeted to African-American individuals and families influencing the accumulation of obligatory and leisure-time physical activity, fruit and vegetable consumption, sedentary behaviour, preference for calorie-dense, nutrient-poor foods, and psychosocial mediators of behavioural change. By participating in interactive experiential learning activities, structured physical activity, policy advocacy, and health education activities, African-American youth (p.336) improved levels of physical activity, nutrition knowledge, self-efficacy, and motivation, and enhanced their ability to navigate barriers to healthy behaviours and reinforce facilitators to healthy habits. Participants ranged from low to high risk of overweight and obesity, with interventions delivered in settings including pre-school, school, after-school programme, and community centre. Physical activity emphasis All of these studies involved regular structured physical activity participation as an intervention component. In those conducted within schools, physical activity was primarily facilitated by modified PE in which the traditional curriculum was replaced with vigorous strength training (e.g., circuit weight training), continuous aerobics (e.g., aerobic dance), active sports (e.g., soccer), and skill mastery, conducted in small groups to maximize time spent being active (Bayne-Smith et al., 2004; Young et al., 2006). Stephens and Wentz (1998) augmented traditional PE with 20-minute supplementary bouts of aerobic activity three days per week incorporated into classroom instruction (Stephens & Wentz, 1998). Studies conducted in after-school and community based settings offered more varied approaches to physical activity promotion. The Students and Parents Actively Involved in Being Fit study engaged families collectively in a variety of supervised dance, sports games, traditional calisthenics and other fitness activities during four weekly 60- to 75-minute sessions (Engels et

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al., 2005). Youth engaged in the America SCORES Bay Area project accumulated up to 6 hours of after-school soccer instruction, practice, and competition over three days per week (Madsen et al., 2009). Medical College of Georgia's FitKid project provided 80 minutes of physical activity daily through an after-school programme, rotating activity themes each month in order to maintain participant interest (Gutin et al., 2008; Yin et al., 2005). Nutrition emphasis Stolley and Fitzgibbon (1997) conducted an intervention to improve dietary intake among African-American mothers and their daughters. The 12-week project focused on helping participants lower the fat and cholesterol in their diets (Fitzgibbon et al., 1995; Stolley & Fitzgibbon, 1997). Comprehensive Comprehensive interventions also employed a variety of physical activity strategies. Several conducted within a federally funded trial were aimed at preventing excess weight gain in preadolescent African-American girls. Girls' Health Enrichment Multi-Site Studies (GEMS) included participation in a non-resident summer day camp where several physical activity sessions were incorporated throughout the day (Baranowski et al., 2003); engagement of children and parents in culturally relevant dance classes and aerobic activities (i.e. African dance, hip-hop, disco) within a community setting (Beech et al., 2003); girls’ participation in structured dance choreography classes five days per week at three local community centres (Robinson et al., 2003); and participation in after-school girls’ ‘club meetings’ where dancing and physical activities games (e.g., double dutch, hopscotch, tag, relay races) were featured as agenda items (Story et al., 2003). Baranowski et al. (1990) employed both structured and freestyle strategies to facilitate activity participation (Baranowski et al., 1990). During seven weekly education sessions conducted at study outset, African-American youth and their families participated in group-led aerobic activities to complement the core component of the study, free access to a gym facility twice weekly. Participants were trained in the use of aerobic and resistance equipment, and encouraged to build and sustain personal exercise programmes. (p.337) Key findings Few significant effects were demonstrated across these studies. Investigators typically attributed this to small sample sizes and the resulting lack of statistical power, as nonsignificant effects in the desired direction were identified in most studies (Kumanyika et al., 2003). Kumanyika and colleagues (2003) suggested that the true success of GEMS lay in the successful recruitment and retention of participants – achieving participation goals in three of four studies, and lessons learned about collaboration and cross-cultural interactions throughout the experience (Kumanyika et al., 2003). Two center studies (Memphis, Stanford) have proceeded to full-scale intervention trials that are currently in progress. FitKid intervention participants improved their overall fitness and decreased their body fat percentage; however, effects dissipated during summer breaks when not engaged in intervention activities (Gutin et al., 2008). Stolley & Fitzgibbon (1997) demonstrated that the mothers in their study made more significant changes in regard to dietary intake than their daughters, a promising finding in that parents may serve as role models, and usually purchase or shop for and prepare meals for their children (Stolley & Fitzgibbon, 1997).

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Effects were more robust when interventions were conducted in settings where youngsters normally congregated (i.e. captive audiences) (Bayne-Smith et al., 2004; Beech et al., 2003; Engels et al., 2005; Robinson et al., 2003; Stephens & Wentz, 1998; Young et al., 2006). Interventions incorporating culturally salient elements (e.g. popular dances, ‘double dutch’ jump rope, ‘soul food’) produced greater attendance and retention (Beech et al., 2003; Robinson et al., 2003).

Environmental interventions Environmental approaches address the external factors that make it difficult to translate healthy intentions into action. Common targets for intervention among the 13 studies identified as having substantive samples of African-Americans included social interactions with peers and parents, marketing and advertising, food availability and pricing, and physical education policies and practices (Dobbins et al., 2009; Durant et al., 2009; Story et al., 2008; Trost, 2007). School settings, where youth spend half of their waking hours, are prime targets for intervention (Gonzalez-Suarez et al., 2009; Naylor & McKay, 2009). A recent Cochrane review of schoolbased physical activity programmes showed that such interventions have resulted in increased duration of physical activity, decreased TV viewing time, and improved VO2 max and blood cholesterol (Dobbins et al., 2009). Distributing educational materials and modifying school curricula to incorporate more physical activity were the minimum changes needed to realize a significant impact (Dobbins et al., 2009). Nutrition policy has been effectively addressed through expanding adherence to federal nutrition standards, which are typically enforced for school breakfasts and lunches, but do not currently apply to foods sold a la carte (Story et al., 2006). In the absence of stricter standards at the state or local level, many schools use the sales of such popular, nutrient-poor ‘competitive’ foods to increase revenue. An increased presence of a la carte offerings in schools has been found to be associated with a decline in fruit, vegetable, and milk intake, and an increase in total fat and saturated fat intake (Cullen & Zakeri, 2004; Kubik et al., 2003), whereas policies that limit the quality or availability of competitive foods for purchase have been effective in curtailing consumption of such foods (Story et al., 2006). Childcare settings are also prominent targets of intervention. According to the National Center for Educational Statistics, 60% of children spend 29 hours per week in childcare, whereas 41% spend at least 35 hours per week in childcare (Iruka & Carver, 2006). That number is likely higher for African-American children, because of their lower average socioeconomic status (e.g., higher numbers of single and underemployed mothers working long hours with substantial commutes in low-wage jobs and holding multiple jobs) and because many are in informal daycare arrangements not captured in these data. Presently, considerable variation exists in state standards governing the foods and physical (p.338) activity opportunities provided to children in these settings. This variation not only lends to their organizational flexibility to adopt healthier nutrition and fitness practices (Dowda et al., 2005; Yancey, 2006), but also impedes widespread adoption of best practices. A federally regulated childcare programme, Head Start, represents a major exception, and hence, opportunity for large-scale programmatic and policy change to increase physical activity and improve nutritional quality (Story et al., 2006). Pilot studies are beginning to recognize opportunities for intervening in childcare (Gosliner et al.,

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2010; Williams et al., 2009), as well as other federal programmes targeting communities at high risk for obesity (Crawford et al., 2004). The school-based interventions were aimed at modifying the social and physical infrastructure of the school environment. Some interventions targeted schools where 50% or more of the students were eligible for free or reduced lunch fare, based on the finding that children from lower socioeconomic status groups have higher rates of overweight and obesity (Foster et al., 2008; Perry et al., 1998). The community-level interventions addressed social norms related to physical activity and healthy eating among parents and children through various forms of media and special events (Huhman et al., 2008; Yancey et al., 2009a). Physical activity and sedentary behaviour emphasis Environmental approaches to improving levels of physical activity have included modification of the school environment to make activity more appealing, and the use of social marketing to change activity norms among students, parents, teachers, and the broader community. Activityfocused PE instruction was often combined with individual strategies such as health education and behavioural skills training, e.g., self-monitoring and progressive goal-setting (McKenzie et al., 1996; Pate et al., 2005; Webber et al., 2008). The Trial of Activity for Adolescent Girls (TAAG) and Lifestyle Education for Activity Program (LEAP) sought to increase physical activity specifically in girls, and provided a range of attractive activities beyond traditional PE offerings. VERB, a nationwide social marketing campaign promoting physical activity, conducted focus groups with African-American youth and parents, yielding useful data on physical activity preferences, barriers, and motivators. Targeted messaging and special events were created with a focus on individual flair and creativity, showing images of African-American youth engaged in activity, featuring culturally salient fashions and music (Huhman et al., 2008). Another innovative approach has begun to emerge, particularly in low-resource schools that face enormous structural impediments to improving PE and recess duration and quality (e.g., playground space occupied by ‘temporary’ classroom trailers, strict accountability for increasing standardized test scores often diverting activity time for test-taking (including practice drills), overcrowded PE classes and lack of trained PE staff). Several studies, including Planet Health, Energizers, Take 10!/PAAC, Lift Off!/Instant Recess ® and PASS & CATCH focused on integrating short physical activity bouts into school routine, either as a part of the standard academic curriculum (Donnelly et al., 2009; Gortmaker et al., 1999; Murray, 2009; Stewart et al., 2004) or at the beginning of the school day or as breaks in transitioning from one activity or subject to another (Mahar et al., 2006; Mitchell et al., 2010; Richardson et al., 2010). Nutrition emphasis The school setting is optimal for environmental interventions because breakfast, lunch, snacks, and beverages are made available to students through food services or vending machines. Several investigators worked with school administrators to modify nutrition policy, with the aim of improving the nutrient density of food items sold at intervention schools (Foster et al., 2008; Luepker et al., 1996; Perry et al., 1998). Nutrition education was provided to teachers and (p. 339) students, and social marketing helped to reinforce positive messages regarding healthy eating in the school and home environment. The 5-A-Day Power Play Plus programme promoted

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fruits and vegetables by making them attractive and readily available during school meals, sending snack packs home for families to share, and partnering with the food industry to provide fresh produce, special presentations, educational materials, and incentives (Perry et al., 1998). The School Nutrition Policy Initiative (SNPI) worked with community and school partners to remove beverages and snacks inconsistent with the nutrition policy standards from the intervention schools (Foster et al., 2008). Comprehensive The most comprehensive and widely disseminated intervention was the Child and Adolescent Trial for Cardiovascular Health (CATCH) (Luepker et al., 1996; McKenzie et al., 1996; Perry et al., 1997). The study focused on modifying school policy and food service items to decrease sodium, total fat, and saturated fat, while using health education and PE to impart behavioural skills and improve moderate to vigorous physical activity both during and outside of school hours (Luepker et al., 1996; McKenzie et al., 1996). The intervention was pilot tested and then implemented on a large scale, involving 96 schools in four ethnically diverse states. A follow-on (CATCH-ON) study tracked the sustainability of the PE intervention component over a 5-year period (McKenzie et al., 2003). A further augmentation, PASS & CATCH incorporated brief activity breaks into the in-class didactic curriculum (Murray, 2009). Another widely replicated intervention, Planet Health, integrated lessons on nutrition and physical activity into a number of academic subjects throughout the school day; this intervention emphasized fruit and vegetable consumption with cooking classes and healthy snacks, and active alternatives to TV viewing (Gortmaker et al., 1999; Wiecha et al., 2004). Neither CATCH nor Planet Health, however, targeted or included substantial proportions of African Americans, but both included sub-group analyses by race/ethnicity. Several recent environmental interventions specifically targeted African-American and Latino youth. UCLA launched a pilot 8-week randomized trial, with a sample of Latino and AfricanAmerican middle school students in which an adaptation of the SPARK PE approach (Sallis et al., 1997) and 10-minute interactive nutrition education modules including healthy snacks replaced traditional PE (McCarthy et al., 2008; Yancey et al., unpublished data). FriarFit, a public–private partnership between the San Diego Padres Major League Baseball team, The California Endowment foundation, and UCLA to prevent childhood obesity in San Diego added 10 nutrientrich items to the ballpark menu marketed prominently by players and featured a 10-minute Instant Recess break during the pre-game shows of Sunday home games (Yancey et al., 2009a). Healthy Eating Active Communities, an obesity prevention initiative of the same foundation, mobilizes four key sectors – schools, neighbourhoods, health departments and health care providers, and the media – to address the nutrition and physical activity environments of youngsters in six Northern and Southern California communities (Solomon et al., 2009; Samuels et al., 2010). Key findings Planet Health's comprehensive classroom-based physical activity and nutrition instruction was effective in decreasing the prevalence of obesity in girls, with greater effect on black than white girls, in contrast to most studies (Gortmaker et al., 1999). Planet Health was also effective in reducing television viewing and increasing fruit and vegetable intake in girls and boys, and

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decreasing overall energy intake in girls. The UCLA intervention decreased serum cholesterol overall and BMI in boys, and increased self-reported fruit intake in African-Americans (Yancey et al., unpublished data). CATCH's only significant influence on obesity occurred in an adaptation for Latinos that stemmed the rate (p.340) of increase in overweight from grades 3 to 5. Acrossthe-board, CATCH decreased the fat content of school foods and increased minutes of vigorous physical activity. However, anthropometric variables tracked strongly throughout the study, particularly in black children – 96% who began the study in the 5th BMI quintile remained in the 4th or 5th quintiles after 6 years of follow-up (Kelder et al., 2002). In the long-term, although vigorous physical activity declined for intervention schools, the proportion of time in PE classes spent in moderate to vigorous physical activity, as well as energy expenditure among students were maintained. PAAC/Take 10!, a particularly well-designed study because of its objective activity monitoring and 3-year intervention follow-up period, was successful in increasing sessions of moderate to vigorous physical activity during school and non-school time; BMI increases were attenuated over a 3-year period in schools accumulating at least 75 minutes per week of these bouts (Donnelly et al., 2009). Short bouts of classroom-based physical activity positively influenced physical activity levels and organizational outcomes. Staying on task during didactic coursework and not being disruptive, along with actual improvements in academic performance have been demonstrated (Barr-Anderson et al., 2010). Interventions focusing on traditional means of physical activity promotion were successful in increasing time devoted to moderate to vigorous activity (McKenzie et al., 1996; Pate et al., 2005; Webber et al., 2008). The LEAP study found that girls who did not participate in PE at intervention schools still reported higher levels of vigorous physical activity, suggesting that environmental strategies used to encourage activity outside of PE classes, as well as role modelling, were effective in this population (Pate et al., 2005). The VERB campaign found a positive association between message awareness and free-time physical activity in AfricanAmerican youth (Huhman et al., 2008). However, BMI was not significantly reduced. Studies that addressed nutrition policy in schools were successful in improving dietary quality (Foster et al., 2008; Perry et al., 1998), and sometimes in reducing the incidence of obesity. African-American students who attended schools participating in the School Nutrition Policy Initiative were 41% less likely to be overweight at the end of the intervention than those attending control schools (Foster et al., 2008). African-American students in the 5-A-Day Power Play Plus programme significantly decreased their proportion of calories from saturated fat (Perry et al., 1998).

Discussion Successes of interventions Structural interventions may produce modest improvements in BMI progression and risk behaviours in certain sub-samples of students, particularly in low-resource school environments. Opportunities to demonstrate significant effects may actually be greater in settings or populations with very low baseline rates of fitness-promoting behaviours and conditions, as in PAAC/Take 10!'s mitigation of weight gain among students, nearly half of whom qualified for free and reduced priced lunches, the salutary influence of CATCH on weight only in low-income

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schools, or Planet Health's greater effectiveness in preventing obesity in (middle income) black girls. However, these interventions were no more successful in addressing established obesity than conventional clinical treatment approaches (Naar-King et al., 2009; Resnicow et al., 2005; Williamson et al., 2006), as reflected in the intractability of high BMI in CATCH. Comprehensive interventions aimed at both physical (in)activity and eating were more consistently effective in preventing obesity than were single-focus ones. This evidence also lends support for the feasibility and effectiveness of augmenting conventional activity opportunities (PE and recess) with short intervals of physical activity to aid obesity prevention. (p.341) Their ready adaptation to school routine and benefits for outcomes of interest to educators may bode well for their institutionalization. Gender differences in behavioural influences were apparent across studies. The higher number of studies for girls promoting physical activity clearly reflects recognition of their greater risk for inactivity and lower activity levels. However, these data suggest that boys may need special attention with respect to diet. The 5-A-Day Power Play Plus programme found that girls in the intervention sites reported higher rates of vegetable consumption compared to control sites, whereas no difference was found among boys (Perry et al., 1998). Planet Health elicited increases in fruit and vegetable consumption and a lesser rise in total energy intake in girls but not boys (Gortmaker et al., 1999). In contrast, the UCLA study found an attenuation of the agerelated decline in fruit and vegetable intake in both boys and girls (Yancey et al., unpublished data). Gender-specific nutrition interventions should be further studied in order to better target eating behaviours, especially in boys. Despite a number of inherent limitations, individually targeted interventions have a major role in obesity control in young African Americans, many of whom experience intractable obstacles of poverty and low-resource schools, and have more severe levels of obesity and obesity comorbidities requiring aggressive and long-term approaches (Hudson, 2008; Whitt-Glover & Kumanyika, 2009). Although appropriate choice of location and setting are crucial to intervention recruitment, attendance, and retention, the mere fact that they require active attendance (rather than offering the possibility of passive exposure as in environmental interventions) dampens participation, leading to power and generalizability constraints. This is particularly true for low-income African Americans who confront myriad logistical challenges such as childcare, transportation, and work scheduling (Baranowski et al., 1990). In addition, individual interventions are expensive, resource- and labour-intensive, and less capable of engaging large samples of participants (Kumanyika et al., 2003). The challenge is how to intervene cost-effectively and sustainably. Insights on benefits of targeting to African-American population versus general population The VERB campaign's culturally targeted messages likely contributed to its positive effect on physical activity awareness and participation among African-American youth. VERB is an excellent example of including youth in programme development, messaging, and implementation, an emerging trend that may enhance reach and effectiveness (Naylor & McKay, 2009). The devotion of additional resources to this and other minority populations was justified due to disproportionate rates of obesity and obesity-related diseases (Huhman et al., 2008). However, Gutin and colleagues' (2008) findings of eradication of Georgia FitKid Project

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intervention effects during summer breaks also underscores the pervasive toxicity of the environment beyond school walls in many communities (Gutin et al., 2008). Lessons learned from CATCH and Planet Health may be applied here (Franks et al., 2007): 1 Identifying at the outset the staff and resources required for programme implementation and dissemination; 2 Involving key stakeholders (e.g., teachers and other school personnel, students, parents, community-based and professional organizations) during all phases of programme development and dissemination; 3 Planning for dissemination of programmes early in the development and testing process; and 4 Rigorously and continuously evaluating interventions to discern their effects on important population sub-groups and making adjustments accordingly. (p.342) Research directions and implications Obesity may best be prevented by addressing environments both within schools and those proximal to and interfacing with schools (corner stores, fast food restaurants, and after-school programmes), and local governments may play a central role in coordinating these efforts. Surveillance must be enhanced to permit better targeting of intervention efforts and assessment of intervention effects, and scientific journals must enforce reporting of sample demographics, at least by gender and either race/ethnicity, or socioeconomic status (SES) in geographic areas with few ethnic minority groups. African Americans are not monolithic as a group, and their heterogeneity must be recognized as in other minority populations such as Latinos and Asian Americans. Clearly gender is a major factor in intervention development and adaptation, but SES, region of residence, and family, regional or national origins (e.g., Southern US, Caribbean, African immigrant) are also important. Earlier intervention may be necessary in order to attenuate the incidence of obesity, and emerging work in childcare and other infant and toddler services is critically needed. A disproportionate number of the black students in the samples of most studies were already overweight in the primary grades (Foster et al., 2008), and their high chronic disease risk status persisted over time even when interventions were implemented (Kelder et al., 2002). References Bibliography references: Baranowski, T., Baranowski, J.C., Cullen, K.W., et al. (2003) The fun, food, and fitness project (FFFP): the Baylor GEMS pilot study. Ethnicity and Disease 13, S30–S39. Baranowski, T., Simons-Morton, B., Hooks, P., et al. (1990) A center-based program for exercise change among Black-American families. Health Education Quarterly 17, 179–196.

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Pate, R.R., Ward, D.S., Saunders, R.P., Felton, G., Dishman, R.K., & Dowda, M. (2005) Promotion of physical activity among high-school girls: a randomized controlled trial. American Journal of Public Health 95, 1582–1587. Perry, C.L., Bishop, D.B., Taylor, G., et al. (1998) Changing fruit and vegetable consumption among children: the 5-a-day power plus program in St. Paul, Minnesota. American Journal Of Public Health 88, 603–609. Perry, C.L., Sellers, D.E., Johnson, C., et al. (1997) The child and adolescent trial for cardiovascular health (CATCH): intervention, implementation, and feasibility for elementary schools in the United States. Health Education & Behavior 24, 716–735. Resnicow, K., Taylor, R., Baskin, M., & McCarty, F. (2005) Results of go girls: a weight control program for overweight African-American adolescent females. Obesity Research 13(10), 1739– 1748. Richardson, I., Whitt-Glover, M., Heil, D., Yancey, A., & Yore, M. (2010) Dissemination of promising strategies to influence organizational socio-cultural environments to promote physical activity. Active Living Research Annual Meeting. San Diego, ∼CA. Robinson, T.N., Killen, J.D., Kraemer, H.C., et al. (2003) Dance and reducing television viewing to prevent weight gain in African-American girls: the Stanford GEMS pilot study. Ethnicity and Disease 13, S65–S77. Rochon, J., Klesges, R.C., Story, M., et al. (2003) Common design elements of the girls health enrichment multi-site studies (GEMS). Ethnicity and Disease 13, S6–S14. Sallis, J.F., McKenzie, T.L., Alcaraz, J.E., Kolody, B., Faucette, N., & Hovell, M.F. (1997) The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students. Sports, play and active recreation for kids. American Journal of Public Health 87, 1328–1334. Sallis, J.F., Zakarian, J.M., Hovell, M.F., & Hofstetter, C.R. (1996) Ethnic, socioeconomic, and sex differences in physical activity among adolescents. Journal of Clinical Epidemiology 49, 125– 134. Samuels, S.E., Craypo, L., Boyle, M., Crawford, P., Yancey, A., & Flores, G. (2010) The California Endowment’s Healthy Eating Active Communities (HEAC) program: a midpoint review. American Journal of Public Health. Submitted. Solomon, L.S., Standish, M.B., & Orleans, C.T. (2009) Creating physical activity – promoting community environments: time for a breakthrough. Preventive Medicine 49, 334–335. Stephens, M.B. & Wentz, S.W. (1998) Supplemental fitness activities and fitness in urban elementary school classrooms. Family Medicine 30, 220–223.

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Stewart, J.A., Dennison, D.A., Kohl, H.W., & Doyle, J.A. (2004) Exercise level and energy expenditure in the Take 10! in-class physical activity program. Journal of School Health 74, 397– 400. Stolley, M.R. & Fitzgibbon, M.L. (1997) Effects of an obesity prevention program on the eating behavior of African American mothers and daughters. Health Education & Behavior 24, 152– 164. Story, M., Sherwood, N.E., Himes, J.H., et al. (2003) An after-school obesity prevention program for African-American girls: the Minnesota GEMS pilot study. Ethnicity and Disease 13, S54–S64. Story, M., Kaphingst, K.M., & French, S. (2006) The role of schools in obesity prevention. The Future of Children 16, 109–142. Story, M., Kaphingst, K.M., Robinson-O'brien, R., & Glanz, K. (2008) Creating healthy food and eating environments: policy and environmental approaches. Annual Review of Public Health 29, 253–272. Tirodkar, M.A. & Jain, A. (2003) Food messages on African American television shows. American Journal of Public Health 93, 439–441. Trost, S.G. (2007) Active education. Oakland, CA, Active Leaving Research, The California Endowment. Trost, S.G., Sallis, J.F., Pate, R.R., Freedson, P.S., Taylor, W.C., & Dowda, M. (2003) Evaluating a model of parental influence on youth physical activity. American Journal of Preventive Medicine 25, 277–282. UCLA Center To Eliminate Health Disparities, S.A. (2007) Failing fitness: physical activity and physical education in schools. Los Angeles, CA, The California Endowment. Van Duyn, M.A., McCrae, T., Wingrove, B.K., et al. (2007) Adapting evidence-based strategies to increase physical activity among African Americans, Hispanics, Hmong, and Native Hawaiians: a social marketing approach. Preventing Chronic Disease 4, A102. Wang, Y., Liang, H., & Chen, X. (2009) Measured body mass index, body weight perception, dissatisfaction and control practices in urban, low-income African American adolescents. BMC Public Health 9, 183. Ward-Begnoche, W. & Thompson, J. (2008) Economic considerations in treating overweight youth. The Journal of the Arkansas Medical Society 105, 43–45. Webber, L.S., Catellier, D.J., Lytle, L.A., et al. (2008) Promoting physical activity in middle school girls: trial of activity for adolescent girls. American Journal of Preventive Medicine 34, 173–184.

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Whitt-Glover, M.C. & Kumanyika, S.K. (2009) Systematic review of interventions to increase physical activity and physical fitness in African-Americans. American Journal of Health Promotion 23, S33–S56. Whitt-Glover, M.C., Taylor, W.C., Floyd, M.F., Yore, M.M., Yancey, A.K., & Matthews, C.E. (2009) Disparities in physical activity and sedentary behaviors among US children and adolescents: prevalence, correlates, and intervention implications. Journal of Public Health Policy 30, (Suppl. 1) S309–S334. Wiecha, J.L., El Ayadi, A.M., Fuemmeler, B.F., et al. (2004) Diffusion of an integrated health education program in an urban school system: planet health. Journal of Pediatric Psychology 29, 467–474. Williams, C.L., Carter, B.J., Kibbe, D.L., & Dennison, D. (2009) Increasing physical activity in preschool: a pilot study to evaluate animal trackers. Journal of Nutrition Education and Behavior 41, 47–52. Williamson, D.A., Walden, H.M., White, M.A., et al. (2006) Two-year internet-based randomized controlled trial for weight loss in African-American girls. Obesity (Silver Spring) 14(7), 1231– 1243. Yancey, A. (2006) Tackling childhood obesity: requires a shift in social norms, not just an exercise programme. BMJ 333, 1031–1032. Yancey, A. (2009) The meta-volition model: Organizational leadership is the key ingredient in getting society moving, literally! Preventive Medicine 49(4), 342–351. Yancey, A. (2010) Instant recess: building a fit nation – 10 minutes at a time, University of California Press, Berkeley, CA. Yancey, A., Gatchell, M., Brown, E., McCarthy, W., & Diamant, A. (2003) Diabetes is a major health problem for African Americans. UCLA Center For Health Policy Research, Los Angeles, CA. Yancey, A.K., Ory, M.G., & Davis, S.M. (2006a) Dissemination of physical activity promotion interventions in underserved populations. American Journal of Preventive Medicine 31, S82– S91. Yancey, A.K., Simon, P.A., McCarthy, W.J., Lightstone, A.S., & Fielding, J.E. (2006b) Ethnic and sex variations in overweight self-perception: relationship to sedentariness. Obesity (Silver Spring) 14, 980–988. Yancey, A.K., Fielding, J.E., Flores, G.R., Sallis, J.F., McCarthy, W.J., & Breslow, L. (2007) Creating a robust public health infrastructure for physical activity promotion. American Journal of Preventive Medicine 32, 68–78. Yancey, A., Winfield, D., Larsen, J., et al. (2009a) 'Live, learn and play': building strategic alliances between professional sports and public health. Preventive Medicine 49, 322–325.

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Yancey, A.K., Cole, B.L., Brown, R., et al. (2009b) A cross-sectional prevalence study of ethnically targeted and general audience outdoor obesity-related advertising. Milbank Quarterly 87, 155–184. Yancey, A., McCarthy, W., Wong, W., Siegel, J., Gewa, C., & Leslie, J. Promoting physical activity and healthy nutrition through a physical education replacement intervention. Unpublished data. Yancey, A.K., Grant, D., Kurosky, S., Kravitz-Wirtz, N., & Mistry, R. (2010) Role modeling, risk, and resilience in California adolescents. Journal of Adolescent Health. In press. Yin, Z., Gutin, B., Johnson, M.H., et al. (2005) An environmental approach to obesity prevention in children: medical college of Georgia fitkid project year 1 results. Obesity Research 13, 2153– 2161. Young, D.R., Phillips, J.A., Yu, T., & Haythornthwaite, J.A. (2006) Effects of a life skills intervention for increasing physical activity in adolescent girls. Archives of Pediatric and Adolescent Medicine 160, 1255–1261.

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University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Targeted approaches by culturally appropriate programmes Shiriki Kumanyika

DOI:10.1093/acprof:oso/9780199572915.003.0030

Abstract and Keywords The development of childhood obesity is linked to socio-cultural, economic, and environmental transitions that result in excess availability of low cost, high energy processed foods and soft drinks coupled with decreased physical activity and increased opportunities for sedentary pursuits, such as television watching. Reducing obesity prevalence requires stabilizing population weight levels and, particularly, preventing excess weight gain from childhood onward through interventions on diet and physical activity. The World Health Organization concludes that, with respect to diet and physical activity interventions, ‘What is known is that interventions in low- and middle-income countries should be sufficiently adapted to the cultural context and involve community members — both in the formative assessment, intervention design, and implementation — for the intervention to work’. Culturally appropriate interventions are also important with respect to culturally distinctive ethnic minority populations in high income countries, associated with observations of higher obesity levels or steeper trends of increase in these populations. This chapter highlights selected ongoing or completed studies of obesity prevention in ethnic minority populations in the United States, the United Kingdom, and Australia, exemplifying various approaches to cultural appropriateness and suggesting directions for advancing knowledge and practice.

Keywords: ethnic minority, obesity, children, intervention, eating, health promotion, physical activity, African American, race, culture

Chapter summary The epidemic of childhood obesity is linked to socio-cultural, economic, and environmental transitions that result in excess availability of low cost, high energy processed foods and soft drinks coupled with decreased physical activity and increased opportunities for sedentary

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pursuits such as television watching. Reducing obesity prevalence requires stabilizing population weight levels and, particularly, preventing excess weight gain from childhood onward through interventions on diet and physical activity. The World Health Organization concludes that, with respect to diet and physical activity interventions, ‘What is known is that interventions in low- and middle-income countries should be sufficiently adapted to the cultural context and involve community members – both in the formative assessment, intervention design, and implementation – for the intervention to work’. Culturally appropriate interventions are also important with respect to culturally distinctive ethnic minority populations in high income countries, associated with observations of higher obesity levels or steeper trends of increase in these populations. This chapter highlights selected ongoing or completed studies of obesity prevention in ethnic minority populations in the United States, the United Kingdom, and Australia, exemplifying various approaches to cultural appropriateness and suggesting directions for advancing knowledge and practice.

Background Ethnic differences in obesity prevalence Higher than average obesity prevalence or rate of increase in obesity relative to the respective national or regional reference population has been documented among children and adolescents in African American and Hispanic/Latino American and American Indian populations in the United States (Anderson & Whitaker, 2009; Ogden et al., 2010; Singh et al., 2010); AfroCaribbeans and South Asians in the United Kingdom (Saxena et al., 2004); Turkish immigrants in the Netherlands (de Wilde et al., 2009); Aboriginal populations in Australia (O'Dea, 2008); and Pacific Islander populations in the United States, Australia, New Zealand, and the Pacific Islands (O'Dea, 2008; Singh et al., 2010; Utter et al., 2008). When typical cutoffs for obesity are used, Asian populations may appear to have lower than average risk (Table 30.1). However, metabolic and cardiovascular disease (CVD) risks associated with weight gain and abdominal obesity occur in Asian populations at lower BMI levels compared to others (WHO, 2004). Hence, Asian populations are also included among ethnic populations warranting special attention with respect to obesity prevention. The question of what it is about ethnic or cultural variables that can be sufficiently different, and systematic, to lead to the observed inequalities in obesity is intriguing, and far from resolved. (p.349)

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Table 30.1 Obesity prevalence for ethnic groups within the United States, England, the Netherlands, and Australia Ethnic group

Population and data source* and Year

Age group (yrs) and gender Males

USA (Ogden et al., 2010) National Health and Nutrition Examination Survey (NHANES), 2007–2008; % of children with CDC age-sex specific BMI ≥ 95th percentile

USA (Singh et al., 2010) National Survey of Children’s Health (NSCH), 2007 (parent-reported weight and height); % of children with CDC age– sex specific BMI ≥ 95th percentile

England (Saxena et al., 2004) Health Survey for England, 1999; % of children with BMI equivalent to IOTF adult BMI 〉 25

Females

2 to 5

6–11

12 to 19

2 to 5

6–11

12 to 19

Non-Hispanic White

6.6†

20.5

16.7

12.0

17.4

14.5

Non-Hispanic Black

11.1

17.7

19.8

11.7

21.1

29.2

Hispanic

17.8

28.3

25.5

10.4

21.9

17.5

Males and females combined, ages 10–17 Non-Hispanic White

12.9

Non-Hispanic Black

23.9

Hispanic

23.4

American Indian

23.0

Asian

8.7

Hawaiian/Pacific Islander

20.9 Males aged 2 to 20 yrs Females aged 2 to 20 yrs

General population

21.7

22.3

Afro-Caribbean

22.6

33.3

Indian

29.6

24.0

Pakistani

26.2

25.7

Bangladeshi

14.2

20.7

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Population and data source* and Year

Ethnic group

Chinese The Hague, Netherlands (de Wilde et al., 2009) Electronic health records from nutrition surveillance, 2007; % of children with BMI equivalent to IOTF adult BMI 〉 30

Age group (yrs) and gender Males

Females

14.4

13.0

3 to 6

7 to10

13 to 16

3 to 6

7 to10

13 to 16

Dutch

1.2

4.2

2.5

3.5

3.6

2.3

Turkish

11.1

14.0

16.0

8.4

14.2

8.8

Moroccan

5.9

8.7

8.3

6.3

6.6

7.1

Surinamese South Asian

3.4

7.7

5.4

2.9

6.9

4.0

Males

Australia (O'Dea, 2008) National Youth Cultures of Eating Study, 2006; % of children with BMI equivalent to IOTF adult BMI 〉 30

Females

6 to 11

12 to 18

Anglo/Caucasian

5.5

7.0

5.5

4.6

Aboriginal/Torres Strait Islanders

8.6

6.8

6.8

9.1

Chinese/Southeast Asians

9.5

5.6

2.0

2.6

Middle East

10.0

21.9

13.3

17.2

Pacific Islands/Maori 18.6

23.6

15.6

23.4

*

6 to 11

Measured weight and height unless otherwise noted † estimate does not meet standard of statistical reliability.

CDC = Centers for Disease Control and Prevention IOTF = International Obesity Task Force.

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(p.350) (p.351) However, it is clear that genetic differences do not explain population-level differences in obesity. For example, early observations of high levels of obesity in adult Pima Indians were initially interpreted as reflecting a particular genetic predisposition to obesity, but subsequent comparison with genetically similar populations elsewhere, who were less obese, highlighted the role of environmental factors in the expression of obesity (Schulz et al., 2006). Similarly, comparisons of people of African descent living in Africa, the Caribbean, the United Kingdom, and the United States show a gradient of increasing obesity prevalence with increasing exposure to westernized environments (Luke et al., 2001). Further evidence of the influence of environmental variables comes from studies showing that the obesity levels of immigrants approach or even exceed the levels of obesity in the new country over time and with succeeding generations (Gordon-Larsen et al., 2003; Lauderdale & Rathouz, 2000; Tremblay et al., 2005). Ethnic differences in obesity are linked to related factors such as socioeconomic status, or social position. Attention to cultural variables is motivated by observations that ethnic differences persist even after stratification or adjustment for socioeconomic status (SES) (Wang & Beydoun, 2007; Waters et al., 2008). The term ‘culture’ is used to refer to such residual differences. Yet this is incomplete; the determinants of high levels of obesity in populations can only be understood fully with an ecological model. Cultural appropriateness actually encompasses not only socio-cultural but also physical, economic, and policy environmental contexts (Kumanyika, 2008; Mavoa & McCabe, 2008; Swinburn et al., 1999). The concept of culturally appropriate interventions Depending on the age group and the setting, focal points for obesity prevention in children and adolescents may include breastfeeding and other aspects of infant and young child feeding, types of foods and beverages available at school and at home, and policies related to accessing these foods and beverages; parent and child knowledge; child behaviours such as skipping breakfast, consumption of high calorie snack foods, television time or other screen media use; neighbourhood access to healthful foods and to opportunities for outdoor physical activity; and peer influences (Koplan et al., 2005). Culturally influenced attitudes and social norms related to eating, body size, various types of physical activity, family and social relationships, media use, and consumer behaviour may be viewed as potential assets or liabilities for intervention success. However, generalities about how ethnicity or culture influences obesity development or are relevant to obesity prevention programmes are not warranted. An overarching principle in achieving cultural appropriateness is that the patterns of relevant cultural and contextual influences must be directly assessed in the community of interest (Kreuter et al., 2003; Resnicow et al., 1999). Whether the goal of culturally appropriate interventions is to help preserve or leverage culturally supported attitudes and behaviours or to discourage them depends on a group’s present and past circumstances. Acculturation and assimilation towards Western diets and physical activity patterns or improved socioeconomic conditions may improve or worsen eating patterns from a health perspective (Kumanyika, 2006). Traditional or commonly consumed foods that are high in fat or sugar may limit uptake of advice related to diet. Acceptance of larger body sizes may limit recognition of the health consequences of obesity. Breastfeeding rates may be higher and traditional foods more healthful in some ethnic groups compared to the general population. In other cases protective dietary or physical activity

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traditions may have been lost due to social circumstances, particularly where there has been social trauma and cultural disruption due to enslavement or political oppression. Because the interest is usually in groups of children not selected on the basis of weight status, obesity prevention interventions often focus on child care, school, or after-school programmes as the primary setting, with family and community components added. Social cognitive theory is (p.352) often cited as the basis for behavioural change components. This is also true of interventions designed for cultural appropriateness. Cultural adaptations are applied to incorporate preferred learning modes, language, and symbolic representations, role models, and traditions. Several frameworks or tools that can guide the design or analysis of efforts to achieve cultural appropriateness are worthy of mention. Resnicow (Resnicow et al., 1999) and Kreuter (Kreuter et al., 2003) differentiate surface or peripheral cultural adaptations that may increase face validity, familiarity, and salience from those that attempt greater cultural depth through involvement of community members or constituents in intervention delivery or partnerships designed to create community ownership and long-term sustainability. Kreuter et al. (2003) also differentiate targeted, ‘one size fits all’ approaches that ignore within-group diversity from ‘tailored’ approaches that include individual level tailoring. Airhihenbuwa’s PEN-3 model provides a framework for designing health programmes in which cultural considerations are at the core of programme design, drawing on concepts from key behavioural change theories that do not explicitly address cultural influences. Fitzgibbon and Beech illustrate how this model can be used to highlight cultural considerations for school based BMI screening as a basis for child obesity prevention programmes (Fitzgibbon & Beech, 2009). An expanded obesity research paradigm developed by the African American Collaborative Obesity Research Network (AACORN) views weight control behaviours and energy balance issues as derivatives of more fundamental biosocial processes emanating from influences at the intersection of a group’s historical and social contexts, cultural and psychosocial processes, and physical and economic environments. In addition, the AACORN model articulates the potential differences in interventions depending on whether those involved in intervention design are community members, researchers who also identify themselves as members of the same ethnic group or community, researchers who are interested in but not ‘of’ the community, or some combination of such community insiders and outsiders. Investigators in the Girls Health Enrichment Multisite Studies (GEMS) developed a detailed matrix as a checklist of potential considerations for intervention development. The matrix prompts for consideration of programme design and delivery variables (including cultural perspectives of investigators and staff), child and family characteristics, and environmental context variables in relation to ethnicity and socioeconomic status influences and key aspects of programme content (Kumanyika et al., 2003b). Swinburn’s ANGELO (Analysis Grid for Environments Linked to Obesity) model has been directly used in the Obesity Prevention in Communities (OPIC) studies, as a tool for developing culturally and contextually relevant interventions that consider socio-cultural, physical, economic, and policy environments (Schultz et al., 2007). Castro offers an approach to resolving the complex issues of ‘fidelity vs. fit’, that is, how to balance the need to keep certain critical elements of an intervention intact while also

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allowing sufficient flexibility to adapt a programme to a specific population and community context (Castro et al., 2004).

Insights from examples of culturally appropriate obesity prevention programmes in youth Within the still relatively limited evidence on obesity prevention in children and adolescents, the number of studies that focus on ethnic populations, even when including diet and physical activity interventions that were not specifically intended to alter body weight levels or rate of weight gain, is extremely small (Brown & Summerbell, 2009; Flynn et al., 2006; Hudson, 2008; Meininger, 2000; Monasta, 2009; Renzaho et al., 2009; Teufel-Shone et al., 2009; Whitt-Glover & Kumanyika, 2009; Wilson, 2009). Table 30.2 gives brief highlights of studies that represent the experience to date with culturally appropriate interventions in the child obesity prevention field. The studies (p.353) listed focus on pre-school children, school age children and adolescents, in order. School settings are the most common, as in the childhood obesity prevention field overall. Studies in after-school, faith organizations, or whole community settings also are included. Most studies of culturally appropriate interventions in the published literature in English have been conducted in the United States. Populations in the studies in Table 30.2 include African American and Latino children in the United States, children in indigenous populations in the United States and Canada, African descent or South Asian children in the United Kingdom, and Pacific Islander children in the Australia-Pacific region. Some studies are efficacy studies in that programmes were designed and evaluated by researchers under conditions that would not necessarily be replicable in natural settings. Others are evaluations of programmes developed with the intent of being sustained in the participating communities. The point of these study descriptions is to illustrate the range of activities undertaken at the formative stage with respect to achieving cultural appropriateness. Five reported outcome data for body size or composition measures. The Hip Hop to Health trial in African American (but not Latino) pre-school children, the school based El Paso CATCH study, and the ABC study in Chinese American children and families reported statistically significant effects on BMI after 2 years, 3 years, and 8 months, respectively. The Kahnawake Schools Project in Canada showed initial effects that were not sustained at the 8-year follow up. The Pathways study did not show an effect on body fat at 3 years. The other studies listed were either short-term pilot studies or, if full-scale studies such as OPIC, have not yet reported outcomes. Based on these studies, following are comments on what we know and need to know about culturally appropriate interventions to prevent obesity in youth. Culturally adapted interventions differ primarily on: the group and setting targeted; how the core content – which is the same as that for obesity prevention programmes in general – is augmented and adapted; and how the intervention is delivered (e.g. ethnicity and source of intervention staff, curriculum delivery, or types of family or community activities based on results of formative assessments and community or stakeholder engagement during intervention development and implementation). Ironically perhaps, the greater the community engagement and ownership, the greater is the potential for implicit cultural adaptations rather than explicit articulation of specific elements of the programme that are being changed. The fact that an intervention is initiated by the

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community or implemented by community role models may provide for cultural appropriateness in ways that cannot be readily identified or understood by outsiders. Teufel-Shone et al. (2009) from their systematic review of interventions to improve physical activity in American Indians and Alaska Natives, noted that explicit references to cultural adaptations were most likely to occur in studies or programme descriptions where leadership was not seated in the relevant tribal entity or entities. Although not included in the Table 30.2 notations, culturally appropriate interventions often differ in the instruments used for assessments of behavioural or attitudinal elements, to ensure that language or other aspects of questionnaires are culturally sensitive or specific and also to directly assess acculturation, assimilation, or socio-cultural influences such as body image or food and physical activity preferences. It is possible that efforts to design interventions that are multifocal and multilevel are given more emphasis in studies designed to be culturally appropriate. The need to take the broader environmental contexts into account is more obvious when working with populations for whom environmental contexts include elements that differ in part from those for the general population. The question of what constitutes success of culturally appropriate interventions is more difficult. What constitutes success in an obesity prevention intervention is itself complex because so few interventions actually have a statistically significant influence on BMI or body fat while showing (p.354) Table 30.2 Examples of studies designed for cultural appropriateness in diverse populations and settings Hip-Hop to Health Jr . (African American and Latino 3 to 5-year-old children; United States) Hip-Hop to Health Jr was conducted in 24 ‘Head-Start’ pre-school education programmes in Chicago, Illinois from 1999 to 2004 (Fitzgibbon et al., 2002; Fitzgibbon et al., 2005; Fitzgibbon et al., 2006). The objective was to assess the efficacy of an obesity prevention intervention compared to a general health intervention with African American children (with an RCT at 12 of the sites) and with Latino children (with an RCT at the other 12 sites) over 2 consecutive years. The formative phase of intervention development involved a 3-week pilot study to explore feasibility and acceptability of both the parent and child components of the programme, subsequent revisions to the approach, and identification of specific elements for improving cultural appropriateness. The authors identified several adaptations for cultural appropriateness: 1) family orientation, 2) easy and safe access to the programme, 3) content that included attention to environmental influences on exercise and diet; 4) encouraging the participants to identify with the intervention staff as role models, 5) actual demonstrations of the recommended lifestyle changes, 6) content suitable for diverse literacy levels, and 7) the bilingual curriculum and programme delivery at the Latino centres. In the African American component, the increase in mean BMI at 2 years post intervention was lower for children in the weight control intervention compared to the general health intervention by 0.65 kg/m2 (p=.008). In the primarily Latino centres the increase in mean BMI at 2 years post intervention was lower for children in the weight control intervention by 0.24 kg/m2, which was not statistically significant (p=.34). Pathways (American Indian 7- to 10-year-old children; United States)

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The Pathways study was conducted within diverse American Indian Communities in Arizona, New Mexico, and South Dakota (Caballero et al., 2003; Davis et al., 2003; Davis et al., 1999; Gittelsohn et al., 1998; Gittelsohn et al., 1999; Snyder et al., 1999; Teufel et al., 1999). The project, conducted in 1993–2000, was motivated by the high rates of obesity among children in American Indian communities. The goal was to develop and evaluate a culturally appropriate, school-based, multi-component intervention to promote healthful eating and physical activity behaviours in 7- to 10-year-old children (grades 3 through 5), with the explicit intention of preventing obesity. The four intervention components were developed in close collaboration with American Indian members of the study team, as well as a broader network of tribal representatives: 1) a curriculum for classroom delivery, 2) changes to school food service, 3) physical education, and 4) a family component. Formative assessment approaches involved school officials, teachers, food service staff, children, and parents or other caregivers. Methods included direct observations of school and community activities and resources and child food purchasing and consumption behaviour, focus groups with teachers and parents, open-ended and semi-structured interviews, and pilot and feasibility testing. The resulting programme framework was based on cultural heritage relating to physical activity, active games, nutritious low fat foods and the incorporation of customs, traditions, beliefs, and values of participating American Indian nations. Indigenous learning modes were incorporated, including storytelling (a journey of two fictional American Indian children), learning through play, learning cooperatively, and learning through reflection. Evaluation involved a large-scale (1704 children in 41 schools) randomized, controlled trial (RCT) with 3 consecutive years of follow up. Pathways provides a well-documented model of using extensive formative research and stakeholder consultation to inform the development of an obesity prevention intervention. Positive results of the study included the strong community support for the intervention and statistically significant changes in knowledge, fat in school lunches, and children’s fat intake. However, there was no effect on percent body fat, which was the primary study outcome, or on physical activity. Kahnawake Schools Diabetes Prevention Project (KSDPP) (Mohawk Indian 6- to 11year-old children; Canada) KSDPP was conducted in collaboration with a Mohawk Indian Community near Montreal, Canada (Macaulay et al., 1997; Paradis et al., 2005) to promote healthy eating and increased physical activity in primary school aged children in their two schools. The programme was initiated in 1994 in response to community leaders’ concerns about the high prevalence of diabetes and related complications (Potvin et al., 2003). KSDPP provides a model of obesity prevention undertaken as a community mobilization and aligned with principles of community based participatory research (CBPR). The school component of the intervention was developed by local school nurses and a nutritionist. Guided by a 40 member community action board (CAB), the programme involved an array of other parent sponsored and community based events. The intervention included school- and community-based activities for teachers, students, and families and school policy changes. Community activities included food preparation, tasting, and promotion of traditional food as well as environmental changes, fitness activities and events, and media activities. The school curriculum with traditional learning styles, was delivered by teachers, most of them from the Mohawk community. The evaluation component has been substantial but secondary to the development and implementation of a sustainable programme. The evaluation design uses a mixed cross sectional and longitudinal design with periodic assessments in KSDPP schools and, for comparison, in Mohawk children from a nearby community not exposed to the programme. The programme is viewed as successful with respect to community engagement and sustainability. The programme initially demonstrated positive effects on skinfold thickness, physical activity, television watching, and fitness measures. However these earlier benefits were no longer observed in the 8-year evaluation (Paradis et al., 2005).

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El Paso Coordinated Approach to Child Health (CATCH) (Mexican American 8-year-old children; United States) The Child and Adolescent Trial for Cardiovascular Health (CATCH), a school based programme designed for 3rd to 5th grade children, was evaluated in 96 U.S. schools nationally in the early 1990s. CATCH demonstrated effectiveness for changing school health systems and child behaviour related to CVD risk reduction, using four components (physical education, food service, classroom curriculum, and families) The El Paso CATCH study reports results of an evaluation of the programme as it was translated and implemented in schools in El Paso, Texas, with primarily Hispanic students from low income families (Coleman et al., 2005; Heath & Coleman, 2003; Heath & Coleman, 2002). The CATCH programme adoption, cultural adaptation, and institutionalization in the school system took place over several years beginning in 1997, emanating from an initiative of a local foundation interested in improving diet and exercise profiles of area residents (Heath & Coleman, 2003). The evaluation study, which compared four CATCH schools with four that had not yet implemented the programme, using a matched quasi-experimental design, began in 1999 and followed children through grades 4 and 5. Results for changes in fitness, physical activity, and school meals were variable but the rate of increase in risk of overweight or obesity was significantly lower in CATCH versus control schools: 2% increase versus 13% increase in girls, and 1% versus 9% in boys. Birmingham healthy Eating and Active Lifestyle for Children Study (BEACHeS) (South Asian 6- to 8-year-old children; England) BEACHeS was a 3-year project to develop interventions to prevent obesity among South Asian school children ages 6 to 8 years (University of Birmingham), for subsequent testing on a larger scale. The project was motivated by the particular risks of diabetes and heart disease in the South Asian population. Formative activities included focus groups (one conducted in Punjabi) with a range of local stakeholders and key informants, such as parents, teachers, administrators, catering staff, health professionals, local public officials and business leaders, personnel from local recreation centres and representatives of the community. Potential programme components were identified for families, the community, and schools and those that were both popular and deemed feasible were further developed and piloted. Cultural context issues raised as barriers to programme uptake and implementation included parental perceptions of their child’s weight, the potential for conflict with parenting styles, the acceptability of mixed gender activities, characteristics of social networks, health professionals’ understanding of the local culture, safety, cost issues, and the pervasiveness of promotion of unhealthy foods in the media. Facilitators or assets identified included shared goals and collaborations among community agencies and voluntary organizations. Formative evaluation activities involved testing of the intervention package in four of eight participating schools, with four other schools that were not provided with the intervention involved as controls. Study results that led to refinement of the intervention were reported. Girls health Enrichment Multisite Studies (GEMS) (8- to 10-year-old African American girls; United States)

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GEMS was a 7-year (1999–2006) two-phase research project to develop and evaluate site specific obesity prevention programmes for 8- to 10-year-old African American girls outside of school settings (Beech et al., 2003; Baranowski et al., 2003; Klesges et al., 2008; Kumanyika et al., 2003a; Kumanyika et al., 2003b; Robinson et al., 2003; Robinson et al., 2008; Story et al., 2003). This initiative was motivated by longstanding observations of high obesity prevalence in African American women and more recent, rapid increases in obesity among African American girls. Sites for the first phase formative research and pilot studies were in Houston, Texas, Memphis, Tennessee, Minneapolis, Minnesota, and East Palo Alto, and Oakland California. Extensive formative research geared to exploring cultural considerations as well as practical aspects of programme design used both centralized and locally developed protocols and included focus groups, interviews with children, parents and key informants, and surveys. Cultural components were identified through an extensive collaborative process of centralized and site-specific formative assessments that considered programmatic, child, family, and environmental context variables relevant to eating, physical activity, and body image. Specific cultural components included the strong family focus and consideration of African American parent–child interaction patterns and media use habits, content designed to address girls’ and parents’ cultural perceptions of weight and physical attractiveness, cultural food preferences, and culturally appealing types of dance and other forms of physical activity. Twelve-week pilot studies at two sites (Memphis and East Palo Alto) showed sufficiently promising results to support refinement and testing of full scale interventions in RCTs with 2 years of follow up: The Memphis and Stanford GEMS trials (Klesges et al., 2008; Robinson et al., 2008). Both of these trials were implemented in part with children and families from predominantly low income communities. The Memphis programme focused on nutrition and physical activity and involved joint and separate caregiver–child group sessions at the community centres, as well as field trips to provide experiences with healthy eating and physical activity in community settings. The East Palo Alto programme (Stanford programme) was implemented in nearby Oakland, California, and focused on physical activity (culturally tailored dance activities); this programme also included a home-based family programme designed to reduce screen media use. Active Balance Childhood (ABC) Study (Chinese American 8- to 10-year-old children; United States) The ABC study was motivated by awareness of the need for programmes to address obesity related risks among Chinese American children (Chen et al., 2009). The small-scale study evaluated a family focused, individually tailored intervention with 67 8- to 10-year-olds recruited from Chinese language programmes in San Francisco, of whom about half were overweight or obese. An 8-week intervention involving group sessions for children and two parent workshops was evaluated using a randomized, waiting-list control design in which controls were children placed on a waiting list for later intervention. Cultural appropriateness aspects of the programme were described in terms of the family focus, the involvement of bi-lingual and bi-cultural researchers, and individual tailoring of advice for each family based on assessment of cultural perspectives. A prior, pre-, and post-test pilot study of a tailored mail-based version of the intervention describes a detailed process of translating, adapting, and testing of publicly available intervention materials for language appropriateness and understanding by mothers (Chen et al., 2008). Outcomes 8 months after enrollment (6 months post intervention) indicated lower BMI, diastolic blood pressure, and dietary fat intake and increased physical activity and fruit and vegetable intake among children in the intervention group (p 〈.05). UK DiEt and Active Living (DEAL) Study (8- to 13-year-old children black, South Asian, and white children in London)

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DEAL is an exploratory study to develop and evaluate obesity or diet and physical activity risk reduction interventions for feasibility and cultural acceptability with ethnic minority and white British children in London (Maynard et al., 2009). Unique aspects of this study are the exploration of the feasibility of undertaking interventions in different settings – primary and secondary school settings and places of worship relevant to the several relevant religious faiths – as well as the attempt to reach African origin (Black African and Afro Black Caribbean) and South Asian (Indian, Pakistani, and Bangladeshi) populations. The study was motivated by awareness of the higher levels of obesity or CVD risk among children in these populations. The formative assessment activities involved focus groups, interviews, and questionnaires with children, parents, and grandparents and with religious leaders as well as more broad-based engagement with community organizations, networks, and members to assess perspectives and support for the interventions. Focus group data analyses and community engagement were ongoing at the time of the published report from this study. Potential intervention components were piloted on a small scale and evaluated with qualitative group and individual debriefing (written evaluations and a focus group). Themes emerging from the formative activities suggested greater feasibility of implementing interventions in school settings compared to places of worship, although places of worship may be more conducive than schools to discussion of cultural traditions and also provide access to family members. Another interesting finding was the need for language translation and perhaps other specific cultural adaptations for older family members, (e.g. grandparents). Pacific OPIC (Obesity Prevention in Communities) Project (European and Pacific Islander adolescents in Australia, Fiji, Tonga, and New Zealand) The OPIC studies were motivated by rates of obesity in the Pacific region – described by the study investigators as ‘the highest in the world’, combined with the limited capacity in Pacific nations and communities to respond to this problem. The interventions focus on high school students but are comprehensive, whole community interventions. There is a strong emphasis on understanding socio-cultural factors related to obesity, as well as on policy and environmental change, including cultural change, and on building capacity of Pacific populations for obesity research (Schultz et al., 2007; Swinburn et al., 2007; Utter et al., 2008). Extensive baseline surveys and interviews were undertaken to inform the development of community action plans (e.g., to assure congruency of strategies with stage of readiness, as well as cultural appropriateness). Strategy development took place at 2-day workshops using the ANGELO process at each study site to obtain broad-based student and community and stakeholder participation. These community action plans guided interventions initiated in 2005. Intervention results are not yet available. The evaluation uses a quasi-experimental design with BMI as the primary outcome. Comparison groups differed somewhat by site. They were selected to be comparable on ethnicity, socioeconomic status, and obesity characteristics but sufficiently distant to avoid exposure to the intervention. (p.355) (p.356) (p.357) (p.358) significant changes on behaviour measures, in the desired direction. In this sense the studies designed to be culturally appropriate appear to be neither better nor worse than other studies. What is clear, and this relates to culturally adapted studies in general, is that these studies are usually not designed to isolate the ‘value added’ by the cultural component. Hence the question of whether cultural adaptations are really necessary (i.e., if they do not improve outcomes over and above non-adapted approaches) can be raised. This question may be unanswerable in that it may be infeasible and unethical to offer interventions that are culturally inappropriate. Given the ultimate intent of establishing effective programmes within the ethnic communities of interest, the most relevant measures of success may include a combination of the following: ◆ a theoretically and culturally appropriate approach, as assessed by programme analysis and community feedback;

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◆ evidence of changes in attitudes and behaviours or policies and environmental characteristics in the desired direction; ◆ evidence of potential sustainability, as reflected, for example, in community interest and community capacity; ◆ evidence of a lack of harm from the programme with respect to child, family, and community quality of life; ◆ a plan for progressively refining the intervention approach and delivery in ways that will eventually increase the effective dose and, therefore, outcomes. The above criteria are consistent with the programme logic that underlies appropriately contextualized obesity prevention programmes, as outlined by the Institute of Medicine (Koplan et al., 2007).

Conclusions In conclusion, the studies reviewed here, although selected, represent the majority of the available experience with culturally appropriate interventions to prevent obesity in youth. There are other interventions in ethnic populations that do not specify whether or how cultural influences were addressed. There are also programmes taking place that might not be identified by scholarly reviews. If research is to contribute to our understanding in this area, a much greater emphasis is needed on studies in ethnic populations. Conventions with respect to how these studies are described in published reports are also needed so that the study processes and outcomes can be more readily understood and compared. At present what we need to know is much greater than what is known, although the urgency of reaching ethnic populations with particularly powerful interventions is great and will probably increase. References Bibliography references: Anderson, S.E. & Whitaker, R.C. (2009) Prevalence of obesity among US preschool children in different racial and ethnic groups. Archives of Pediatric and Adolescent Medicine 163, 344–348. Baranowski, T., Baranowski, J.C., Cullen, K.W., Thompson, D.I., Nicklas, T., Zakeri, I.E., & Rochon, J. (2003) The Fun, Food, And Fitness Project (FFFP): the Baylor GEMS pilot study. Ethnicity and Disease 13, S30–S39. Beech, B.M., Klesges, R.C., Kumanyika, S.K., et al. (2003) Child- and parent-targeted interventions: the Memphis GEMS pilot study. Ethnicity and Disease 13, S40–S53. Brown, T. & Summerbell, C. (2009) Systematic review of school-based interventions that focus on changing dietary intake and physical activity levels to prevent childhood obesity: an update to the obesity guidance produced by the National Institute for Health and Clinical Excellence. Obesity Reviews 10, 110–141.

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Caballero, B., Clay, T., Davis, S.M., et al. (2003) Pathways: A school-based, randomized controlled trial for the prevention of obesity in American Indian schoolchildren. The American Journal of Clinical Nutrition 78, 1030–1038. Castro, F.G., Barrera, M., Jr., & Martinez, C.R., Jr. (2004) The cultural adaptation of prevention interventions: resolving tensions between fidelity and fit. Prevention Science 5, 41–45. Chen, J.L., Weiss, S., Heyman, M.B., & Lustig, R.H. (2009) Efficacy Of A child-centred and family-based program in promoting healthy weight and healthy behaviors in Chinese American children: a randomized controlled study. Journal of Public Health (Oxford). Chen, J.L., Weiss, S., Heyman, M.B., Vittinghoff, E., & Lustig, R. (2008) Pilot study of an individually tailored educational program by mail to promote healthy weight in Chinese American children. Journal for Specialists in Pediatric Nursing 13, 212–222. Coleman, K.J., Tiller, C.L., Sanchez, J., et al. (2005) Prevention of the epidemic increase in child risk of overweight in low-income schools: the El Paso coordinated approach to child health. Archives of Pediatric and Adolescent Medicine 159, 217–224. Davis, S.M., Clay, T., Smyth, M., et al. (2003) Pathways curriculum and family interventions to promote healthful eating and physical activity in American Indian schoolchildren. Preventive Medicine 37, S24–S34. Davis, S.M., Going, S.B., Helitzer, D.L., et al. (1999) Pathways: a culturally appropriate obesityprevention program for American Indian schoolchildren. The American Journal of Clinical Nutrition 69, 796s–802s. De Wilde, J.A., Van Dommelen, P., Middelkoop, B.J., & Verkerk, P.H. (2009) Trends in overweight and obesity prevalence in Dutch, Turkish, Moroccan and Surinamese South Asian children in the Netherlands. Archives of Disease in Childhood 94, 795–800. Fitzgibbon, M.L. & Beech, B.M. (2009) The role of culture in the context of school-based BMI screening. Pediatrics 124, (Suppl. 1) S50–S62. Fitzgibbon, M.L., Stolley, M.R., Dyer, A.R., Vanhorn, L., & Kauferchristoffel, K. (2002) A community-based obesity prevention program for minority children: rationale and study design for hip-hop to health Jr. Preventive Medicine 34, 289–297. Fitzgibbon, M.L., Stolley, M.R., Schiffer, L., Van Horn, L., Kauferchristoffel, K., & Dyer, A. (2005) Two-year follow-up results for hip-hop to health Jr.: a randomized controlled trial for overweight prevention in preschool minority children. Journal of Pediatrics 146, 618–625. Fitzgibbon, M.L., Stolley, M.R., Schiffer, L., Van Horn, L., Kauferchristoffel, K., & Dyer, A. (2006) Hip-hop to health Jr. for Latino preschool children. Obesity (Silver Spring) 14, 1616– 1625.

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Flynn, M.A., Mcneil, D.A., Maloff, B., et al. (2006) Reducing obesity and related chronic disease risk in children and youth: a synthesis of evidence with ‘best practice’ recommendations. Obesity Reviews 7, (Suppl. 1) 7–66. Gittelsohn, J., Evans, M., Helitzer, D., et al. (1998) Formative research in a school-based obesity prevention program for Native American school children (Pathways). Health Education Research 13, 251–265. Gittelsohn, J., Evans, M., Story, M., et al. (1999) Multisite formative assessment for the pathways studyto prevent obesity in American Indian schoolchildren. The American Journal of Clinical Nutrition 69, 767s–772s. Gordon-Larsen, P., Harris, K.M., Ward, D.S., & Popkin, B.M. (2003) Acculturation and overweight-related behaviors among Hispanic immigrants to the US: the national longitudinal study of adolescent health. Social Science and Medicine 57, 2023–2034. Heath, E.M. & Coleman, K.J. (2002) Evaluation of the institutionalization of the coordinated approach to child health (CATCH) in a U.S./Mexico border community. Health Education and Behavior 29, 444–460. Heath, E.M. & Coleman, K.J. (2003) Adoption and institutionalization of the child and adolescent trial for cardiovascular health (CATCH) in El Paso, Texas. Health Promotion Practice 4, 157–164. Hudson, C.E. (2008) An integrative review of obesity prevention in African American children. Issues In Comprehensive Pediatric Nursing 31, 147–170. Klesges, R.C., Obarzanek, E., Klesges, L.M., et al. (2008) Memphis girls health enrichment multisite studies (GEMS): phase 2: design and baseline. Contemporary Clinical Trials 29, 42–55. Koplan, J.P., Liverman C.T., Kraak, V.I. (Ed.) (2005) Preventing childhood obesity, health in the balance. National Academies Press, Washington, D.C. Koplan, J.P., Liverman C.T., Kraak, V.I., Wisham, S.L. (Ed.) (2007) Progress in preventing childhood obesity. How do we measure up? National Academies Press, Washington, D.C. Kreuter, M.W., Lukwago, S.N., Bucholtz, R.D., Clark, E.M., & Sanders-Thompson, V. (2003) Achieving cultural appropriateness in health promotion programs: targeted and tailored approaches. Health Education and Behavior 30, 133–146. Kumanyika, S. (2006) Nutrition and chronic disease prevention: priorities for US minority groups. Nutrition Reviews 64, S9–S14. Kumanyika, S.K. (2008) Environmental influences on childhood obesity: ethnic and cultural influences in context. Physiology and Behavior 94, 61–70. Kumanyika, S.K., Obarzanek, E., Robinson, T.N., & Beech, B.M. (2003a) Phase 1 of the girls health enrichment multi-site studies (GEMS): conclusion. Ethnicity and Disease 13, S88–S91.

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Kumanyika, S.K., Story, M., Beech, B.M., et al. (2003b) Collaborative planning for formative assessment and cultural appropriateness in the girls health enrichment multi-site studies (GEMS): a retrospection. Ethnicity and Disease 13, S15–S29. Lauderdale, D.S. & Rathouz, P.J. (2000) Body mass index in a US national sample of Asian Americans: effects of nativity, years since immigration and socioeconomic status. International Journal of Obesity 24, 1188–1194. Luke, A., Cooper, R.S., Prewitt, T.E., Adeyemo, A.A., & Forrester, T.E. (2001) Nutritional consequences of the African diaspora. Annual Reviews of Nutrition 21, 47–71. Macaulay, A.C., Paradis, G., Potvin, L., et al. (1997) The Kahnawake schools diabetes prevention project: intervention, evaluation, and baseline results of a diabetes primary prevention program with a native community in Canada. Preventive Medicine 26, 779–790. Mavoa, H.M. & Mccabe, M. (2008) Sociocultural factors relating to Tongans' and indigenous Fijians' patterns of eating, physical activity, and body size. Asia Pacific Journal of Clinical Nutrition 17, 375–384. Maynard, M.J., Baker, G., Rawlins, E., Anderson, A., & Harding, S. (2009) Developing obesity prevention interventions among minority ethnic children in schools and places of worship: the deal (diet and active living) study. BMC Public Health 9, 480. Meininger, J.C. (2000) School-based interventions for primary prevention of cardiovascular disease: evidence of effects for minority populations. Annual Review of Nursing Research 18, 219–244. Monasta, L. (2009) Interventions to prevent overweight and obesity in preschool children. Public Health 123, 517. O'dea, J.A. (2008) Gender, ethnicity, culture and social class influences on childhood obesity among Australian schoolchildren: implications for treatment, prevention and community education. Health and Social Care in the Community 16, 282–290. Ogden, C.L., Carroll, M.D., Curtin, L.R., Lamb, M.M., & Flegal, K.M. (2010) Prevalence of high body mass index in US children and adolescents, 2007–2008. JAMA: the Journal of the American Medical Association. Paradis, G., Levesque, L., Macaulay, A.C., et al. (2005) Impact of a diabetes prevention program on body size, physical activity, and diet among Kanien'keha:Ka (Mohawk) children 6 to 11 years old: 8-year results from the Kahnawake schools diabetes prevention project. Pediatrics 115, 333–339. Potvin, L., Cargo, M., Mccomber, A.M., Delormier, T., & Macaulay, A.C. (2003) Implementing participatory intervention and research in communities: lessons from the Kahnawake schools diabetes prevention project in Canada. Social Science and Medicine 56, 1295–1305.

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Renzaho, A.M., Mellor, D., Boulton, K., & Swinburn, B. (2009) Effectiveness of prevention programmes for obesity and chronic diseases among immigrants to developed countries – a systematic review. Public Health and Nutrition 1–13. Resnicow, K., Baranowski, T., Ahluwalia, J.S., & Braithwaite, R.L. (1999) Cultural sensitivity in public health: defined and demystified. Ethnicity and Disease 9, 10–21. Robinson, T.N., Killen, J.D., Kraemer, H.C., Wilson, D.M., Matheson, D.M., Haskell, W.L., et al. (2003) Dance and reducing television viewing to prevent weight gain in African-American girls: the Stanford GEMS pilot study. Ethnicity and Disease 13, S65–S77. Robinson, T.N., Kraemer, H.C., Matheson, D.M., et al. (2008) Stanford GEMS phase 2 obesity prevention trial for low-income African-American girls: design and sample baseline characteristics. Contemporary Clinical Trials 29, 56–69. Saxena, S., Ambler, G., Cole, T.J., & Majeed, A. (2004) Ethnic group differences in overweight and obese children and young people in England: cross sectional survey. Archives of Diseases in Childhood 89, 30–36. Schulz, L.O., Bennett, P.H., Ravussin, E., et al. (2006) Effects of traditional and Western environments on prevalence of type 2 diabetes in Pima Indians in Mexico and the U.S. Diabetes Care 29, 1866–1871. Schultz, J., Utter, J., Mathews, L., Cama, T., Mavoa, H., & Swinburn, B. (2007) The Pacific OPIC project (obesity prevention in communities): action plans and interventions. Pacific Health Dialog 14, 147–153. Singh, G.K., Siahpush, M., & Kogan, M.D. (2010) Rising social inequalities in US childhood obesity, 2003–2007. Annals of Epidemiology 20, 40–52. Snyder, P., Anliker, J., Cunningham-Sabo, L., et al. (1999) The pathways study: a model for lowering the fat in school meals. The American Journal of Clinical Nutrition 69, 810s–815s. Story, M., Sherwood, N.E., Himes, J.H., et al. (2003) An after-school obesity prevention program for African-American girls: the Minnesota GEMS pilot study. Ethnicity and Disease 13, S54–S64. Swinburn, B., Egger, G., & Raza, F. (1999) Dissecting obesogenic environments: the development and application of a framework for identifying and prioritizing environmental interventions for obesity. Preventive Medicine 29, 563–570. Swinburn, B., Pryor, J., Mccabe, M., et al. (2007) The Pacific OPIC project (Obesity Prevention In Communities) – objectives and designs. Pacific Health Dialog 14, 139–146. Teufel-Shone, N.I., Fitzgerald, C., Teufel-Shone, L., & Gamber, M. (2009) Systematic review of physical activity interventions implemented with American Indian and Alaska native populations in the United States and Canada. American Journal of Health Promotion 23, S8–S32.

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Teufel, N.I., Perry, C.L., Story, M., et al. (1999) Pathways family intervention for third-grade American Indian children. The American Journal of Clinical Nutrition 69, 803s–809s. Tremblay, M.S., Perez, C.E., Ardern, C.I., Bryan, S.N., & Katzmarzyk, P.T. (2005) Obesity, overweight and ethnicity. Health Reports 16, 23–34. University of Birmingham Birmingham healthy eating and active lifestyles for children study (BEACHEES). Edgbaston, Birmingham, United Kingdom, . Utter, J., Faeamani, G., Malakellis, M, et al. (2008) Lifestyle and obesity in South Pacific youth. Baseline results from the Pacific obesity prevention in communities (OPIC) project in New Zealand, Fiji, Tonga and Australia, University of Aukland, Aukland, N.Z. Wang, Y. & Beydoun, M.A. (2007) The obesity epidemic in the United States – gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and metaregression analysis. Epidemiology Reviews 29, 6–28. Waters, E., Ashbolt, R., Gibbs, L., et al. (2008) Double disadvantage: the influence of ethnicity over socioeconomic position on childhood overweight and obesity: findings from an inner urban population of primary school children. International Journal of Pediatric Obesity 3, 196–204. Whitt-Glover, M.C. & Kumanyika, S.K. (2009) Systematic review of interventions to increase physical activity and physical fitness in African-Americans. American Journal of Health Promotion 23, S33–S56. WHO (2000) Obesity. Preventing and managing the global epidemic. Report of a WHO expert committee, Geneva, World Health Organization. WHO (2004) Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet 363, 157–163. Wilson, D.K. (2009) New perspectives on health disparities and obesity interventions in youth. Journal of Pediatric Psychology 34, 231–244. World Health Organization (2009) Interventions on diet and physical activity: what works. Summary Report.

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Weight-related teasing and anti-teasing initiatives in schools

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Weight-related teasing and anti-teasing initiatives in schools Jess Haines

DOI:10.1093/acprof:oso/9780199572915.003.0031

Abstract and Keywords Weight or body size is a common focus of teasing among youth. Being teased about one's weight (or weight-related teasing) is associated with adverse psychosocial and behavioural outcomes that may put youth at risk for developing eating disorders and obesity. For example, weightrelated teasing is associated with greater body dissatisfaction, which is an established risk factor for eating disorders and is also associated with binge eating behaviours and lower levels of physical activity. Thus, intervention programs aimed at reducing weight-related teasing among youth have the potential to prevent eating disorders and obesity. This chapter provides details of research at the University of Minnesota, which has aimed to increase understanding of the psychosocial and behavioural consequences of obesity and weight-related bias, specifically teasing. The research seeks to guide the development of interventions aimed at preventing obesity and other weight-related disorders among children and adolescents.

Keywords: weight, stigma, teasing, bullying, overweight, obesity, children, intervention, health promotion, physical activity

Chapter summary Weight or body size is a common focus of teasing among youth. Being teased about one’s weight, or weight-related teasing as referred to it in this chapter, is associated with adverse psychosocial and behavioural outcomes that may put youth at risk for developing eating disorders and obesity. For example, weight-related teasing is associated with greater body dissatisfaction, which is an established risk factor for eating disorders and is also associated with binge eating behaviours and lower levels of physical activity (Field et al., 2003; NeumarkSztainer et al., 2006; Stice et al., 2005). Thus, intervention programmes aimed at reducing weight-related teasing among youth have the potential to prevent eating disorders and obesity.

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This chapter provides details of the research conducted by the author and colleagues at the University of Minnesota, which has aimed to increase our understanding of the psychosocial and behavioural consequences of obesity and weight-related bias, specifically teasing, and is discussed here in order to guide the development of interventions aimed at preventing obesity and other weight-related disorders among children and adolescents.

Introduction Although teasing has been defined as ‘a playful provocation in which one person comments on something of relevance to the target’ (Keltner et al., 2001:243), research has shown that this seemingly benign interaction can have deleterious effects on psychosocial well-being of children and adolescents (Keltner et al., 2001). The most extreme consequence of teasing for society is violence, including suicide and murder. There have been a number of case reports of children and adolescents who committed suicide largely because they were teased by peers (CBC News, 2000; Plaisance & Johnson, 2009; Young, 2009). Recent shootings – including those in Colorado, Kentucky, Arkansas, Oregon, and Mississippi – were committed by children who cited being teased and picked on by peers as motivation for their actions (Blank, 1997; Cowley, 1998; Egan, 1998).

Prevalence and epidemiology of weight-related teasing Weight-related teasing by peers Population-based studies show that weight-related teasing is a common occurrence in the lives of children and adolescents, with female youth reporting higher levels of weight-related teasing by peers than their male counterparts (Neumark-Sztainer et al., 2002a) As might be expected, weight-related teasing is reported more often among overweight and obese adolescents and children than among those who are of average weight. A recent study of 151 fourth through sixth grade students (p.364) found that weight-related teasing by peers was reported by 45% of overweight children (defined as having a BMI ≥ 85th percentile for age and sex), compared to 15% of average weight children (defined as having a BMI ≥ 15th 〈85th percentile for age and sex) (Haines et al., 2006). Hayden-Wade et al. found a similar positive association between teasing and weight among elementary school children (Hayden-Wade et al., 2005). Weightrelated teasing by peers also disproportionately affects overweight and obese adolescents. Using data from Project EAT, Neumark-Sztainer et al. found that teasing by peers was reported by 63% of obese adolescent girls (defined as having a BMI ≥ 95th percentile for age and sex) compared to 21% of average weight adolescent girls. Among boys, teasing by peers was reported by 58% of obese boys and 13% of average weight boys (Neumark-Sztainer et al., 2002a). Reports from a 5-year (from 1999 to 2004) longitudinal study of weight-related teasing among Project EAT participants found that the prevalence of weight-related teasing decreased as adolescents transitioned from early adolescence to mid-adolescence and from mid-adolescence to older adolescence. The study also explored age-matched secular trends among middle adolescents and found that the prevalence of weight-related teasing had remained relatively stable between 1999 and 2004 (Haines et al., 2008). Few studies have examined the prevalence of weight-related teasing across race and ethnicity in youth (Puhl & Latner, 2007). Using data from Project EAT, van den Berg et al. compared the

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prevalence of weight-related teasing by peers among adolescents who reported they are white, black, Hispanic or Latino, Asian-American, or ‘other’, which included Native American, Hawaiian-Pacific-Islander, and mixed race/ethnicity (van den Berg et al., 2008). Regarding teasing by peers, there was a significant difference across race/ethnicity in adolescent boys. Teasing by peers was reported by 19% of Asian-American boys, 22% of black boys, and 21% of Hispanic boys, as compared to 27% of white boys. There was also a significant difference across race/ethnicity in adolescent girls. Approximately 24% of Asian-American girls reported peer teasing, which was significantly less than white girls (31%). The prevalence of weight-related teasing among adolescent girls who identified as black, Hispanic, or Latina, or ‘other’ did not differ significantly from that reported by white girls. Akan and Grilo found similar results in their examination of childhood teasing experiences among female college students; weightrelated teasing did not differ between white and African-American students, but Asian-American students reported significantly less weight-related teasing (Akan & Grilo, 1995). Weight-related teasing by family members Compared to studies exploring teasing by peers, fewer studies have examined weight-related teasing by family members (Neumark-Sztainer et al., 2002a). In their study of 372 middle school girls, Keery et al. found 23% reported that their parents teased them about their appearance, 12% reported their parents teased them about their weight, and 29% reported that their siblings teased them about their appearance (Keery et al., 2005). Data from Project EAT suggests that, like weight-teasing by peers, weight-related teasing by family members is more prevalent among females and among overweight youth. Neumark-Sztainer et al. found that teasing by family members was reported by 47% of obese adolescent girls compared to 24% of average weight adolescent girls. Among boys, teasing by family members was reported by 34% of obese boys and 11% of average weight boys (Neumark-Sztainer et al., 2002a). Weight teasing by family members showed significant differences across race/ethnicity among adolescent girls participating in Project EAT; approximately 34% of Hispanic, 34% of AsianAmerican, and 37% of mixed/other girls reported weight-related teasing by family members, as compared to 25% of white girls. Prevalence of weight-related teasing by families did not differ significantly among white and black girls and there were no significant differences across race in reported family teasing among boys (van den Berg et al., 2008).

(p.365) Consequences of weight-related teasing As shown in the previous section, overweight youth report more frequent weight-related teasing compared to their average weight peers. As described in the following section, research suggests that weight-related teasing may have psychological and behavioural consequences, such as increased body dissatisfaction and increased use of disordered eating behaviours, which could place youth who experience teasing at greater risk for further weight gain and for clinical eating disorders (Field et al., 2003; Neumark-Sztainer et al., 2006; Stice et al., 2005). Psychological consequences of weight-related teasing Weight-related teasing is associated with adverse psychological outcomes, including body dissatisfaction, depression, lower self-esteem, and suicidal ideation. Table 31.1 provides an overview of studies examining the association between weight-related teasing and these psychological outcomes among child and/or adolescent populations.

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Numerous cross-sectional studies among both population-based and clinical samples of youth have found that those who are being teased about their weight have poorer psychological profiles than those who are not teased (van den Berg et al., 2002; Lunner et al., 2000; Keery et al., 2005; Shroff & Thompson, 2004). Project EAT reported that being teased about body weight by family members and/or peers was consistently associated with poorer scores in body satisfaction (Neumark-Sztainer et al., 2002a), self-esteem, depressive symptoms, and higher percentages of youth reporting suicide ideation and suicide attempts (Eisenberg et al., 2003). These associations held for both boys and girls, across racial and ethnic groups and weight groups. BMI was not significantly associated with most outcome measures after teasing was entered into multivariate models indicating that the experience of being teased about weight, rather than actual body weight, appears to be the relevant factor for body satisfaction, selfesteem, depressive symptoms, and suicidal ideation and attempts (Eisenberg et al., 2003; Neumark-Sztainer et al., 2002a). Longitudinal analyses from Project EAT found that teasing at baseline predicted lower body satisfaction, lower self-esteem, and higher depressive symptoms at 5-year follow-up, suggesting that weight-related teasing during adolescence can have a lasting effect on the emotional health of youth (Eisenberg et al., 2006). Although most published studies have found a significant association between weight-related teasing and psychological outcomes, including body dissatisfaction, it is noteworthy that certain studies have found the association between teasing and body dissatisfaction to be fully explained by other social factors, such as pressure to be thin and social support (Stice & Whitenton, 2002). It is also of note that the associations between weight-related teasing and psychological outcomes have been replicated across race in the United States (Young-Hyman et al., 2003) and cross-culturally in the United States, Australia (van den Berg et al., 2002; Lunner et al., 2000), Sweden (Lunner et al., 2000), Netherlands (Muris & Littel, 2005), India (Shroff & Thompson, 2004), and China (Jackson & Chen, 2007). For example, Jackson and Chen found that Chinese adolescents who met the full diagnostic criteria for an eating disorder reported significantly more weight-related teasing than their less symptomatic peers (Jackson & Chen, 2007). Behavioural consequences of weight-related teasing Studies have found associations between weight teasing and weight-related behaviours, including physical activity, dietary intake, and disordered eating behaviours, such as binge eating and purging behaviours. Table 31.2 provides an overview of studies that have examined the association between weight-related teasing and these behavioural outcomes among child and/or adolescent populations. Certain studies examining the impact of weight-related teasing among youth have examined both psychological and behavioural outcomes. Included in Table 31.2 are studies highlighting the behavioural outcomes examined. In Table 31.1, the psychological outcomes are highlighted. (p.366) Table 31.1 Overview of studies examining psychological consequences of weight-related teasing among children and adolescents

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Author(s) and year

Study design

(Eisenberg Crosssectional et al., 2003)

Population studied

Psychological outcome variable(s)

Teasing variable

Results

n = 4746; populationbased sample of adolescents, in USA; 7th– 12th grade; 48.5% Caucasian, 19% AfricanAmerican, 5.8% Hispanic, 19.2% Asian, 3.5 Native American, 4% mixed/ other

Body dissatisfaction, self-esteem, depressive symptoms, suicidal ideation/ suicide attempts

Weightbased teasing by peers or family members

Peer and/or familybased teasing were positively associated with depressive symptoms, low self-esteem, and suicidal ideation/ attempts. Associations were strongest for those who reported both peer and familial teasing, compared to those who reported being teased by a single source.

Body dissatisfaction, self-esteem, depressive symptoms

Weightrelated teasing (source of teasing, e.g., peer or family, not specified)

Time 1 teasing was associated with lower selfesteem, higher body dissatisfaction, and higher depressive symptoms at Time 2.

Weightrelated teasing (source of teasing not specified)

Teasing was found to be a significant predictor for eating disorder psychopathologies at ages 12 and 14 among girls but not among boys.

(Eisenberg Longitudinal n = 2516; et al., population2006) based sample of adolescents in USA; 61.9% Caucasian, 11.1% African American, 4.5% Hispanic, 17.8% Asian, 1.9% Native American and 2.7% mixed/other (Gardner et al., 2000)

Longitudinal n = 189; Eating disorder psychopathology populationbased sample of children in the USA; aged 6–14 years

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Author(s) and year

Study design

Population studied

(HaydenWade et al., 2005)

Crosssectional

(Jackson & Crosssectional Chen, 2007)

Teasing variable

Results

Loneliness, selfn = 156, esteem, weight clinic-based concerns sample of overweight (n = 70) and populationbased sample of nonoverweight (n = 86) children in the USA; age 10–14 years; 80% Caucasian, 4% Hispanic, 4% AfricanAmerican, 3% Asian, 3% multi-racial or other, and 6% did not report

Weightrelated teasing (source of teasing not specified)

Weight-related teasing was associated with higher weight concern and loneliness, and lower confidence in physical appearance.

Anorexia nervosa, bulimia nervosa, bingeeating disorder

Weightrelated teasing (source of teasing not specified)

Participants who met DSM criteria for eating disorder reported significantly more weight-related teasing than their less symptomatic peers.

n = 84; populationbased sample of adolescents in China; age 12–21 years; 42 adolescents who met DSM criteria for eating disorder and 42 matched controls

Psychological outcome variable(s)

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Author(s) and year

Study design

Population studied

Psychological outcome variable(s)

Teasing variable

Results

(Keery et al., 2005)

Crosssectional

n = 372; populationbased sample of middle school girls in USA; mean age = 12.6 years; 85% Caucasian, 5% Hispanic, 2% AfricanAmerican, 2% Native American, 1% Asian, and 4% other

Body dissatisfaction, self-esteem, depressive symptoms

Appearancerelated teasing by family members

Paternal teasing was positively associated with body dissatisfaction and depressive symptoms, and inversely associated with lower self-esteem. Maternal teasing was positively associated with depressive symptoms. Teasing by at least one sibling was positively associated with body dissatisfaction and depressive symptoms, and inversely associated with self-esteem.

(Libbey et al., 2008)

Crosssectional

n = 130; populationbased sample of overweight adolescents in the USA; age 12–20 years; 58.4% white, 13.6% black, 0.8% Hispanic, 2.4% Asian, 7.2% American Indian, 3.2% other, and 14.4% mixed

Disordered eating thoughts, depressive symptoms, anger and anxiety, selfesteem

Weightrelated teasing by peers and family members

Frequency of teasing was positively associated with disordered eating thoughts, depressive symptoms, and anger and anxiety, and inversely associated with self-esteem.

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Author(s) and year

Study design

Population studied

Psychological outcome variable(s)

Teasing variable

Results

(Levine et al., 1994)

Crosssectional

n = 285; populationbased sample of adolescent girls in the USA; age 10– 14 years; 99% Caucasian

Body dissatisfaction, investment in thinness, eating disturbance

Weightrelated teasing by peers and family members

Weight-related teasing by families and by peers was positively associated with body dissatisfaction, investment in thinness, and eating disturbance.

(Lunner et Crosssectional al., 2000)

3 populationbased sample of adolescent girls; 1 from Sweden (n = 260, 8th graders, mean age = 14.3) and 2 from Australia (n = 159, 7th graders mean age = 12.8; n = 210, 8th graders, mean age = 13.7)

Body dissatisfaction, drive for thinness

Weightrelated teasing (source of teasing not specified)

Path analyses revealed that BMI was positively associated with teasing and body dissatisfaction. Body dissatisfaction was positively associated with level of drive for thinness. Weightrelated teasing was found to mediate the association of BMI and body dissatisfaction.

(Muris & Littel, 2005)

n = 130; populationbased sample of adolescents in the Netherlands; age 14–18 years

Eating attitudes, depressive symptoms, social anxiety

History of teasing during childhood (source of teasing not specified)

Positive correlations were found between teasing experiences and social anxiety, depression, and maladaptive eating attitudes.

Crosssectional

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Author(s) and year

Study design

(Shroff & CrossThompson, sectional 2004)

Population studied

Psychological outcome variable(s)

Teasing variable

Results

n = 189; populationbased sample of adolescent females (n = 96; mean age 11.7 years) and young adult females (n = 93; mean age = 18 years) in Bombay, India

Body dissatisfaction, drive for thinness

Weightrelated teasing (source of teasing not specified)

Path analyses revealed that BMI was positively associated with teasing and body dissatisfaction. Weight-related teasing was found to mediate the association of BMI and body dissatisfaction. Among the adolescent sample, weight-related teasing was also positively associated with drive for thinness.

Weightrelated teasing by peers and family members

Weight-related teasing was not found to be significantly associated with body dissatisfaction.

(Stice & Longitudinal n = 496; Body Whitenton, dissatisfaction population2002) based sample of adolescent girls in the USA, age 11– 15 years at baseline, 68% Caucasian, 18% Hispanic, 7% AfricanAmerican, 2% Asian, 1% Native American, and 4% mixed or other

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Author(s) and year

Study design

Population studied

Psychological outcome variable(s)

(Storch et al., 2007)

Crosssectional

n = 92; clinic-based sample of overweight children in the USA; age 8–18 years; 60.9% Caucasian, 32.6% AfricanAmerican, 4% Hispanic, and 2.2% Other

Depressive Teasing by symptoms, peers loneliness, multidimensional anxiety, social physique anxiety, physical activity

Peer teasing was found to be positively associated with depressive symptoms, multidimensional anxiety, loneliness, and social physique anxiety.

(Thompson Longitudinal n = 87; et al., population1995) based sample of adolescent females in the USA; age 10–15 years; 95% Caucasian

Weight dissatisfaction, appearance dissatisfaction, eating disturbance, and global psychological functioning

Weightrelated teasing (source of teasing not specified)

Path analyses revealed that teasing at Time 1 was positively associated with weight and appearance dissatisfaction at Time 2.

(van den CrossBerg et al., sectional 2002)

n = 470; populationbased sample of adolescent girls in Australia; mean age = 15.5

Dietary restraint, bingeing, body dissatisfaction, psychological functioning

Weightrelated teasing (source of teasing not specified)

Structural modeling revealed that teasing was positively associated with body dissatisfaction. Body dissatisfaction was positively associated with global psychological functioning and dietary restraint.

(YoungHyman et al., 2003)

Self-esteem n = 117; clinic-based sample of overweight and obese children in the USA; age 5–10 years; 100% AfricanAmerican

Weightrelated and appearancerelated teasing by peers

Weight-related teasing was inversely associated with self-esteem.

Crosssectional

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Teasing variable

Results

Weight-related teasing and anti-teasing initiatives in schools

Author(s) and year

Study design

Population studied

Psychological outcome variable(s)

Teasing variable

Results

(YoungHyman et al., 2006)

Crosssectional

n = 164; populationbased sample of children in the USA who were overweight or at-risk for overweight; mean age 11.9; 65% white, 35% black

Body size dissatisfaction, depression, trait anxiety

Weightrelated teasing (source of teasing not specified)

Weight-related teasing was positively associated with depression and trait anxiety among the entire sample. Teasing was not associated with depression or anxiety when examined only among black children. For boys, weightrelated teasing was positively associated with body size dissatisfaction.

(p.367) (p.368) (p.369) (p.370) Table 31.2 Overview of studies examining behavioural consequences of weightrelated teasing among children and adolescents Author(s) and year

Study design

Population studied

Behavioural outcome variable(s)

Teasing variable Results

(Bauer et al., 2004)

Qualitative

26 adolescents in the USA; 7th —8th grade; 80% White, 20% Asian American or African American.

Not applicable: qualitative study

Not applicable: In focus group qualitative study interviews, participants identified teasing as a barrier to being physically active. Participants also talked about teasing influencing their food choices and level of comfort eating in the school cafeteria.

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Author(s) and year

Study design

Population studied

Behavioural outcome variable(s)

Teasing variable Results

(Faith et al., 2002)

Crosssectional

n = 576; populationbased adolescents in the USA; mean age = 11.6 years; 87.2% Caucasian

Sports enjoyment, physical activity

General weightrelated teasing (source of teasing not specified); weight-related teasing during sports and activity (source of teasing not specified)

Weight-related teasing during sports or activity was found to be inversely associated with sports enjoyment and mild-intensity physical activity. General weight-related teasing was positively associated with sports enjoyment.

(Field et al., 2008)

Longitudinal n = 12,534; populationbased sample of adolescents in the USA; age 9–15 years; 〉90% Caucasian

Purging, binge Negative eating comments about weight by mother, father, males, and females

Males who received negative comments about weight from their fathers were more likely to initiate bingeeating behaviours. Females who received negative comments about weight from males were more likely to initiate purging behaviours.

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Author(s) and year

Study design

Behavioural outcome variable(s)

Teasing variable Results

(Haines et Longitudinal n=2516; populational., 2006a) based sample of adolescents in the USA; 48.5% Caucasian, 19.0% AfricanAmerican, 19.2% Asian, 5.8% Hispanic, 3.5% Native American, and 3.9% mixed/ other

Binge eating with loss of control, frequent dieting, unhealthy weight control behaviours, i.e., fasting, skipping meals, taking laxatives/ diuretics/ diet pills, vomiting

Weight-related teasing(source of teasing not specified)

Males who were teased about their weight were more likely than their peers to initiate binge eating with loss of control and unhealthy weight control behaviours. Females who were teased were more likely than their peers to become frequent dieters

(HaydenWade et al., 2005)

Preference for isolative or social physically active and sedentary activities

Weight-related teasing (source of teasing not specified)

Weight-related teasing was positively associated with preference for isolative sedentary activities and inversely associated with preference for social physical activities.

Crosssectional

Population studied

n = 156, clinicbased sample of overweight (n = 70) and populationbased sample of nonoverweight (n = 86) children in the USA; age 10–14 years; 80% Caucasian, 4% Hispanic, 4% AfricanAmerican, 3% Asian, 3% multi-racial or other, and 6% did not report

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Author(s) and year

Study design

Population studied

Behavioural outcome variable(s)

(Keery et al., 2005)

Crosssectional

Bulimic n = 372; behaviours populationbased sample of middle school girls in the USA; mean age = 12.6 years; 85% Caucasian, 5% Hispanic, 2% AfricanAmerican, 2% Native American, 1% Asian, and 4% other

(Levine et al., 1994)

Crosssectional

n = 285; populationbased sample of adolescent girls in the USA; age 10– 14 years; 99% Caucasian

(Libbey et al., 2008)

Crosssectional

n = 130; populationbased sample of overweight adolescents in the USA; age 12–20 years; 58.4% white, 13.6% black, 0.8% Hispanic, 2.4% Asian, 7.2% American Indian, 3.2% other, and 14.4% mixed

Teasing variable Results

Appearancerelated teasing by family members

Paternal teasing was positively associated with bulimic behaviours, i.e., bingeing and purging. Teasing by at least one sibling was positively associated with bulimic behaviours.

Weight management behaviours, e.g., fasting, skipping meals

Weight-related teasing by peers and family members

Weight-related teasing by families and by peers was positively associated with weight management behaviours.

Binge eating, unhealthy weight control behaviours, i.e., fasting, skipping meals, taking laxatives/ diuretics/ diet pills, vomiting

Weight-related teasing by peers and family members

Frequency of teasing was positively associated with binge eating and use of unhealthy weight control behaviours.

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Author(s) and year

Study design

Population studied

Behavioural outcome variable(s)

Teasing variable Results

(Neumark- CrossSztainer et sectional al., 2002a)

n = 4736; populationbased sample of adolescents in the USA; 7th —12th grade; 48.5% Caucasian, 19% AfricanAmerican, 5.8% Hispanic, 19.2% Asian, 3.5 Native American, 4% mixed/other

Binge eating, and unhealthy weight-control behaviours, i.e., fasting, skipping meals, taking laxatives/ diuretics/ diet pills, vomiting

Weight-related teasing by peers and family members

(O’Dea, 2003)

Qualitative

n = 213; populationbased sample of children and adolescents in Australia; age 7–17 years

Not applicable: qualitative study

Not applicable: In focus group qualitative study interviews, participants identified teasing as a barrier to being physically active.

(Storch et al., 2007)

Crosssectional

n = 92; clinic- Physical activity based sample of children; age 8–18 years in the USA; 60.9% Caucasian, 32.6% AfricanAmerican, 4% Hispanic, and 2.2% Other

(Wertheim Longitudinal n = 435; et al., adolescent 2001) girls in Australia; grades 7th, 8th, and 10th

Bulimic behaviours, restrictive eating

(p.371) (p.372)

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Weight-related teasing was associated with greater odds of using unhealthy weight-control behaviours and binge eating.

Teasing by peers Peer teasing was found to be inversely associated with physical activity levels.

Weight-related teasing (source of teasing not specified)

Path analysis revealed that weight-related teasing was associated with future bulimic behaviours among participants in two grades (Grade 7 and Grade 10).

Weight-related teasing and anti-teasing initiatives in schools

(p.373) The majority of the research exploring the behavioural consequences of weight-related teasing has focused on the impact of teasing on disordered eating behaviours. Cross-sectional research with both population-based and clinical samples of children and adolescents provide evidence of an association between being teased about weight and disordered eating behaviours (Fabian & Thompson, 1989; Keery et al., 2005; Levine et al., 1994; Neumark-Sztainer et al., 2002a). Project EAT found strong cross-sectional associations between weight-related teasing and binge eating and between teasing and unhealthy weight control behaviours, such as fasting, vomiting, and using diuretics, among overweight and average weight adolescents (NeumarkSztainer et al., 2002a). Unhealthy weight control behaviours were reported by 80% of the overweight girls who perceived that they were teased frequently about their weight and 68% of the overweight girls who were not teased (odds ratio, OR = 2.1). Among overweight boys, the association was stronger; unhealthy weight control behaviours were reported by 62% of the boys who were teased about their weight and 42% of those who were not teased (OR = 3.3). Fewer prospective studies have examined the effects of teasing on the development of disordered eating behaviours. Wertheim, Koerner, and Paxton found that weight-related teasing predicted subsequent levels of bulimic behaviours among 435 adolescent girls residing in Australia (Wertheim et al., 2001). Field et al. examined peer and family influences on the development of disordered eating behaviours among 12,534 adolescents in the United States and found that males who received negative comments about weight from their fathers were more likely to initiate binge eating behaviours and that females who received negative comments about weight from male peers were more likely to initiate purging behaviours (Field et al., 2008). Results from Project EAT found that males who were teased about their weight in adolescence were significantly more likely to initiate binge eating (OR = 3.0) or other unhealthy weight control behaviours (OR = 1.8) over 5 years after adjusting for age, race/ethnicity, socioeconomic status, and BMI. This study also found that females were significantly more likely to initiate frequent dieting (OR = 1.6) if they had been teased about weight during adolescence (Haines et al., 2006a). Although limited, there is some evidence from cross-sectional and qualitative research that being teased about weight may influence physical activity participation and dietary intake. Faith et al. examined the influence of weight-related teasing during physical activity in a non-clinical sample of children and found that children who are teased about their weight by parents or peers during physical activities have higher negative attitudes towards sports and report reduced physical activity levels than peers who were not teased during physical activities (Faith et al., 2002). Storch et al. found a similar inverse association between weight-related teasing and physical activity levels in a clinical sample of at-risk-for-overweight and overweight children and adolescents (Storch et al., 2007). Hayden-Wade and colleagues examined correlates of teasing experiences among overweight children from a fitness camp and a demographically similar sample of non-overweight school children and found that weight-related teasing was positively associated with a preference for isolative sedentary behaviours and inversely associated with a preference for social physical activities (Hayden-Wade et al., 2005). In two, separate qualitative studies, researchers conducted focus groups with students in Australia and the United States with the goal of exploring barriers to healthy eating and physical activity among youth. In both studies, students identified teasing by peers as an important barrier to

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physical activity (Bauer et al., 2004; O'Dea, 2003). In the US study, students also talked about teasing influencing their food choices and level of comfort eating in the school cafeteria (Bauer et al., 2004).

School-based initiatives to reduce weight-related teasing Few obesity or eating disorder prevention interventions have specifically addressed weightrelated teasing. The following describes some of these studies. (p.374) Eating Smart, Eating for Me Eating Smart, Eating for Me is a school-based curriculum designed to encourage healthy eating, exercise, and body image, and reduce dieting, exercising for weight loss, and body dissatisfaction among fourth and fifth grade students (Smolak et al., 1998). The curriculum consists of ten lessons, which addressed a variety of topics, including a session focused on increasing body size acceptance and reducing prejudice against fat and fat people. In addition to the classroom curriculum, the programme includes nine parent newsletters that parallel the classroom lessons. Smolak and colleagues evaluated the effectiveness of the Eating Smart, Eating for Me curriculum among 253 fifth grade, primarily white students in the United States using a pre/post controlled design and found that although there was significant decline in negative attitudes towards fat people among the students who received the intervention as compared to controls, the curriculum had no effect on level of weight-related teasing. Eating disorder prevention programme among students at an elite ballet school Piran used a participatory intervention approach to reduce body weight and shape preoccupation among ballet students in a Canadian residential ballet school (Piran, 1999). The first step of this participatory approach involved dialogues with administration, teachers, and students in focus groups to identify systematic, environmental-level factors that supported the development of body weight and shape preoccupation among the students. These factors were then addressed through subsequent meetings with staff and students. Sessions were held with school staff to help foster cooperation and support for systematic changes. Focus groups were held with the students throughout the year to allow them the opportunity to guide the programme based on their experiences. Through these focus groups students were empowered to identify, explore, and implement strategies to change the structure of their school environment. Although one of the strategies the students implemented was to forbid weightrelated teasing and comments by students and school staff, weight-related teasing was not one of the outcomes examined in the programme’s impact evaluation. Piran et al. did find that the programme was effective in reducing the level of disordered eating behaviours among the students (Piran, 1999). The Eating Disorders Awareness and Prevention (EDAP) puppet programme The EDAP puppet programme was designed to promote in children an acceptance of diverse body shapes, a healthy self-concept, and healthy attitudes about food and eating (Irving, 2000). The programme features four puppet characters: 1) A Caucasian boy who is teased by his peers about being fat; 2) A Caucasian girl who is preoccupied with her weight and what she eats; 3) An African-American girl who is supportive of the other characters; and 4) An African-American

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teacher who helps the children cope with being teased or pressured and teaches them what to do when they feel sad, lonely, or bad about themselves. In addition to the puppet performance, the programme includes a presenter’s manual and education material and activities for children that are designed to reinforce the messages from the puppet performance. Irving conducted an evaluation of the EDAP puppet programme among 152 students at one elementary school in the United States. Although the programme’s effect on teasing behaviour was not assessed, survey data were collected from students after they viewed the performance. This evaluation found that the programme was effective in communicating the message: ‘not to tease others’ (Irving, 2000). (p.375) Healthy Schools – healthy Kids Healthy Schools – Healthy Kids (HSHK) is a school-based eating disorder prevention intervention, which included messages aimed at promoting body size acceptance and reducing weight-related teasing (McVey & Tweed, 2005). The HSHK intervention was implemented in two ethnically diverse public schools in Canada and used both environmental and individual-level approaches to communicate the intervention messages (McVey et al., 2007). Environmentallevel approaches used in HSHK include a parent intervention, sensitivity training for school staff, and school outreach activities (e.g., posters and video presentations) that promoted messages about a non-dieting approach to healthy eating and physical activity, body size acceptance, and general self-acceptance. HSHK’s parent component consisted of workshops led by research staff addressing topics of relevance to adolescence (e.g., body image, self-esteem) and monthly newsletters that addressed topics covered in the class-based curriculum. Individual-level strategies included a six-module classroom-based curriculum that focused on life skills (e.g., media literacy, stress management, communication) and peer support groups. For girls, the peer support groups were held once a week over 12 weeks and focused on life skills and the promotion of a non-dieting approach to nutrition and active living. Boys participated in one, 50-minute peer support session that addressed peer teasing and bullying. McVey et al. assessed the impact of HSHK among 982 sixth and seventh grade students in Canada via a pre/post controlled design using self-report surveys completed at baseline, postintervention (8 months), and at 6-month follow-up. HSHK did not significantly impact teasing among female or male students (McVey et al., 2007). However, at 6-month follow-up, girls who participated in the HSHK programme reported a reduction in the level of internalization of media stereotypes and skipping meals (to lose weight) as compared to girls in the control condition. Very important kids Formative research

Building on previous research, interviews and focus groups were conducted with elementary school children and their teachers and parents at one elementary school in the United States to gain their insight as to how best to address weight-related teasing in a school-based intervention. Teachers and parents recommended that the school implement more explicit rules regarding teasing as a way to reduce weight-related teasing. Students suggested educating students on the impact teasing can have on peers. One student stated:

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‘Like, put ourselves in their shoes. … think about how it would feel to be teased each and every day … I think you should tell them that it would really hurt if you were teased everyday for the rest of the year. Something like that’. Students also discussed strategies for dealing with teasing when it does occur. Teaching skills to defend themselves from teasing or to defend others who are getting teased were discussed as ways to help students deal with teasing when it occurred (Haines et al., 2007). Pilot study

Based on the results of this qualitative research, a pilot test of V.I.K. (Very Important Kids) was conducted, to create a multi-level school-based intervention that is designed to prevent weightrelated teasing (primary outcome) and reduce internalization of the thin-ideal promoted in the media, disordered eating behaviours, and body dissatisfaction (secondary outcomes) among fourth through sixth grade students. The programme was also informed by social cognitive theory (p.376) (Baranowski et al., 1997) and a V.I.K. advisory board comprised various members of the school community. Intervention components were implemented to address factors at the individual and environmental level. At the individual level, the V.I.K. programme included an after-school programme that involved activities directed at changing behavioural and personal factors influencing teasing and disordered eating behaviours, such as self-efficacy to impact teasing. The second individual-level component was a theatre programme, which involved students working with a local theatre company, Illusion Theater (Illusion Theater, 2005), to develop a play based on their own experiences with teasing. Environmental-level strategies used to change social norms at the school regarding teasing and weight included: 1) an educational workshop for school staff; 2) a school-wide no-teasing campaign; and 3) a schoolwide reading of a fictional book about teasing (Lovell, 2001) followed by a discussion led by the classroom teachers. The V.I.K. intervention also had a family component that included post cards, family nights, performance of the V.I.K. play for family members, and the promotion of key V.I.K. messages at parent–teacher nights. To evaluate the effectiveness of V.I.K. a pre/post quasi-experimental design was undertaken in two schools in the United States, with one school assigned to intervention and one to assessment-only control. Both schools served an ethnically diverse, primarily low-income student population. Impact of the V.I.K. programme was assessed on the primary outcome (teasing) and secondary outcomes (media internalization, body satisfaction, and unhealthy weight control behaviours) at baseline and after the 8-month intervention. The V.I.K. intervention was effective in reducing teasing; the prevalence of teasing in the control school increased from 21.1% to 29.8% over the 8-month study period, whereas in the intervention school levels of teasing decreased from 30.2% to 20.6% (Haines et al., 2006b). After controlling for baseline level of overall teasing, BMI z-score, and demographic factors, the odds of students being frequently teased was significantly lower in the intervention school relative to the control school (OR = 0.22). There were no significant differences between the schools in the secondary outcomes examined (media internalization, body satisfaction, and unhealthy weight control behaviours). Significant changes were identified in two key theoretical constructs addressed in the intervention: self-efficacy to impact weight-teasing norms and perceived peer norms regarding teasing and dieting. Potential mediation effects of self-efficacy and peer weight-related norms

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were assessed and found that peer norms mediated the intervention effect for teasing. This finding suggests that researchers and public health practitioners wishing to design interventions to reduce teasing in schools should include activities to change social norms regarding teasing (Irving, 2000; Piran, 1999). Environmental-level intervention strategies, such as those used in the V.I.K. intervention to alter social norms at the intervention school (e.g., a school-wide noteasing campaign and viewing of a theatrical production promoting the no-teasing message), may be useful strategies to change social norms among elementary school children. Although research using a larger sample of schools is needed to confirm these results, the findings of V.I.K. suggest that interventions incorporating individual, home, and school-level strategies focused on changing social norms regarding weight and weight-related teasing may be effective in reducing weight-related teasing among youth.

Chapter summary and implications for future school-based initiatives to reduce weight-related teasing The findings of studies to date suggest that interventions must be designed to ensure there is sufficient focus on the issue of weight-related teasing and that the ‘intervention dose’ is sufficient. Although weight-related teasing was addressed in each of the interventions reviewed, the only intervention that showed positive effect on level of teasing was V.I.K., for which teasing was the (p.377) main focus of the intervention. Second, interventions should address environmental factors, such as social norms and school-level policies, which can influence level of weight-related teasing in schools. Changing these school-level factors requires substantial effort to engage the teachers, administrators, parents, and students. Future research efforts should focus on testing a multi-level, school-based intervention that is focused on decreasing teasing in an adequately powered randomized-controlled trial. References Bibliography references: Akan, G.E. & Grilo, C.M. (1995) Sociocultural influences on eating attitudes and behaviors, body image, and psychological functioning: a comparison of African-American, Asian-American, and Caucasian college women. International Journal of Eating Disorders 18, 181–187. Baranowski, T., Perry, C.L., & Parcel, G.S. (1997) How individuals, environments, and health behavior interact: social cognitive theory. In K. Glanz, F.M. Lewis, & B.K. Rimer (Ed.) Health behavior and health education: theory, research and practice. San Francisco: Jossey-Bass Inc. Bauer, K.W., Yang, Y.W., & Austin, S.B. (2004) ‘How can we stay healthy when you’re throwing all of this in front of us?’ Findings from focus groups and interviews in middle schools on environmental influences on nutrition and physical activity. Health Education and Behavior 31, 34–46. Blank, J. (1997) Prayer circle murders. US News And World Report 123, 24–27. CBC News (2000) Teasing leads to suicide. Cowley, G. (1998) Why children turn violent. Newsweek, 24–25.

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Egan, T. (1998) Where rampages begin. New York Times. Eisenberg, M.E., Neumark-Sztainer, D., & Story, M. (2003) Associations of weight-based teasing and emotional well-being among adolescents. Archives of Pediatric and Adolescent Medicine 157, 733–738. Eisenberg, M.E., Neumark-Sztainer, D., Haines, J., & Wall, M. (2006) Weight-teasing and emotional well-being in adolescents: longitudinal findings from project EAT. Journal of Adolescent Health 38, 675–683. Fabian, L.J. & Thompson, J.K. (1989) Body image and eating disturbance in young females. International Journal Of Eating Disorders 8, 63–74. Faith, M.S., Leone, M.A., Ayers, T.S., Heo, M., & Pietrobelli, A. (2002) Weight criticism during physical activity, coping skills, and reported physical activity in children. Pediatrics 110, E23. Field, A.E., Austin, S.B., Taylor, C.B., et al. (2003) Relation between dieting and weight change among preadolescents and adolescents. Pediatrics 112, 900–906. Field, A.E., Javaras, K.M., Aneja, P., et al. (2008) Family, peer, and media predictors of becoming eating disordered. Archives of Pediatric and Adolescent Medicine 162, 574–579. Gardner, R.M., Stark, K., Friedman, B.N., & Jackson, N.A. (2000) Predictors of eating disorder scores in children ages 6–14: a longitudinal study. Journal of Psychosomatic Research 49, 199– 205. Haines, J., Neumark-Sztainer, D., & Thiel, L. (2007) Addressing weight-related issues in an elementary school: what do students, parents, and school staff recommend? Eating Disorders 15, 5–21. Haines, J., Neumark-Sztainer, D., Eisenberg, M.E., & Hannan, P.J. (2006a) Weight-teasing and disordered eating behaviors: longitudinal findings from project EAT (Eating Among Teens). Pediatrics 117, E209–E215. Haines, J., Neumark-Sztainer, D., Perry, C.L., Hannan, P.J., & Levine, M.P. (2006b) V.I.K. (Very Important Kids): a school-based program designed to reduce teasing and unhealthy weightcontrol behaviors. Health Education Research 21, 884–895. Haines, J., Neumark-Sztainer, D., Hannan, P.J., Van Den Berg, P., & Eisenberg, M.E. (2008) Longitudinal and secular trends in weight-related teasing during adolescence. Obesity (Silver Spring) 16, (Suppl. 2) S18–S23. Hayden-Wade, H.A., Stein, R.I., Ghaderi, A., Saelens, B.E., Zabinski, M.F., & Wilfley, D.E. (2005) Prevalence, characteristics, and correlates of teasing experiences among overweight children vs. non-overweight peers. Obesity Research 13, 1381–1392. Illusion Theater (2005) Illusion theater: education and outreach.

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Irving, L.M. (2000) Promoting size acceptance in elementary school children: the EDAP puppet program. Eating Disorders 8, 221–232. Jackson, T. & Chen, H. (2007) Identifying the eating disorder symptomatic in China: the role of sociocultural factors and culturally defined appearance concerns. Journal of Psychosomatic Research 62, 241–249. Keery, H., Boutelle, K., Van Den Berg, P., & Thompson, J.K. (2005) The impact of appearancerelated teasing by family members. Journal of Adolescent Health 37, 120–127. Keltner, D., Capps, L., Kring, A.M., Young, R.C., & Heerey, E.A. (2001) Just teasing: a conceptual analysis and empirical review. Psychological Bulletin 127, 229–248. Levine, M.P., Smolak, L., & Hayden, H. (1994) The relation of sociocultural factors to eating attitudes and behaviors among middle-school girls. Journal of Early Adolescence 14, 471–490. Libbey, H.P., Story, M.T., Neumark-Sztainer, D.R., & Boutelle, K.N. (2008) Teasing, disordered eating behaviors, and psychological morbidities among overweight adolescents. Obesity (Silver Spring) 16, (Suppl. 2) S24–S29. Lovell, P. (2001) Stand tall, Molly Lou Melon, G.P. Putnum's Sons, New York, NY. Lunner, K., Werthem, E.H., Thompson, J.K., Paxton, S.J., Mcdonald, F., & Halvaarson, K.S. (2000) A cross-cultural examination of weight-related teasing, body image, and eating disturbance in Swedish and Australian samples. International Journal of Eating Disorders 28, 430–435. Mcvey, G.L. & Tweed, S.T. (2005) Healthy schools – healthy kids: a controlled evaluation of a comprehensive eating disorder prevention program. Academy for Eating Disorders International Conference on Eating Disorders. Montreal, QB. Mcvey, G., Tweed, S., & Blackmore, E. (2007) Healthy schools – healthy kids: a controlled evaluation of a comprehensive universal eating disorder prevention program. Body Image 4, 115–136. Muris, P. & Littel, M. (2005) Domains of childhood teasing and psychopathological symptoms in Dutch adolescents. Psychological Reports 96, 707–708. Neumark-Sztainer, D. (2005) ‘I’m, like, so fat!’: helping your teen make healthy choices about eating and exercise in a weight-obsessed world, The Guilford Press, New York. Neumark-Sztainer, D., Story, M., French, S., Hannan, P., Resnick, M., & Blum, R.W. (1997) Psychosocial concerns and health compromising behaviors among overweight and nonoverweight adolescents. Obesity Research 5, 237–249. Neumark-Sztainer, D., Story, M., & Faibisch, L. (1998) Perceived stigmatization among overweight African American and Caucasian adolescent girls. Journal of Adolescent Health 23, 264–270.

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Neumark-Sztainer, D., Story, M., Faibisch, L., Ohlson, J., & Adamiak, M. (1999) Issues of selfimage among overweight African American and Caucasian adolescent girls: a qualitative study. Journal of Nutrition Education 31, 311–320. Neumark-Sztainer, D., Sherwood, N.E., Coller, T., & Hannan, P.J. (2000) Primary prevention of disordered eating among pre-adolescent girls: feasibility and short-term impact of a community based intervention. Journal of the American Dietetic Association 100, 1466–1473. Neumark-Sztainer, D., Falkner, N., Story, M., Perry, C., Hannan, P.J., & Mulert, S. (2002a) Weight-teasing among adolescents: correlations with weight status and disordered eating behaviors. International Journal of Obesity 26, 123–131. Neumark-Sztainer, D., Story, M., Hannan, P.J., Perry, C.L., & Irving, L.M. (2002b) Weightrelated concerns and behaviors among overweight and non-overweight adolescents: implications for preventing weight-related disorders. Archives of Pediatrics and Adolescent Medicine 156, 171–178. Neumark-Sztainer, D., Story, M., Hannan, P.J. & Rex, J. (2003) New moves: a school-based obesity prevention program for adolescent girls. Preventive Medicine 37, 41–51. Neumark-Sztainer, D., Paxton, S.J., Hannan, P.J., Haines, J., & Story, M. (2006) Does body satisfaction matter? Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males. Journal of Adolescent Health 39, 244–251. O'dea, J.A. (2003) Why do kids eat healthful food? Perceived benefits of and barriers to healthful eating and physical activity among children and adolescents. Journal of the American Dietetic Association 103, 497–501. Piran, N. (1999) Eating disorders: a trial of prevention in a high-risk school setting. Journal of Primary Prevention 20, 75–90. Plaisance, M. & Johnson, P. (2009) Mom says Springfield boy, 11, who committed suicide was repeatedly bullied at school. Puhl, R.M. & Latner, J.D. (2007) Stigma, obesity, and the health of the nation's children. Psychological Bulletin 133, 557–580. Shroff, H. & Thompson, J.K. (2004) Body image and eating disturbance in India: media and interpersonal influences. International Journal of Eating Disorders 35, 198–203. Smolak, L., Levine, M.P., & Schermer, F. (1998) A controlled evaluation of an elementary school primary prevention program for eating problems. Journal of Psychosomatic Research 44, 339– 353. Stice, E. & Whitenton, K. (2002) Risk factors for body dissatisfaction in adolescent girls: a longitudinal investigation. Developmental Psychology 38, 669–678.

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Stice, E., Presnell, K., Shaw, H., & Rohde, P. (2005) Psychological and behavioral risk factors for obesity onset in adolescent girls: a prospective study. Journal of Consulting and Clinical Psychology 73, 195–202. Storch, E.A., Milsom, V.A., Debraganza, N., Lewin, A.B., Geffken, G.R., & Silverstein, J.H. (2007) Peer victimization, psychosocial adjustment, and physical activity in overweight and at-risk-foroverweight youth. Journal of Pediatric Psychology 32, 80–89. Thompson, J.K., Coovert, M.D., Richards, K.J., Johnson, S., & Cattarin, J. (1995) Development of body image, eating disturbance, and general psychological functioning in female adolescents: covariance structure modeling and longitudinal investigations. International Journal of Eating Disorders 18, 221–236. Van Den Berg, P., Wertheim, E.H., Thompson, J.K., & Paxton, S.J. (2002) Development of body image, eating disturbance, and general psychological functioning in adolescent females: a replication using covariance structure modeling in an Australian sample. International Journal of Eating Disorders 32, 46–51. Van Den Berg, P., Neumark-Sztainer, D., Eisenberg, M.E., & Haines, J. (2008) Racial/ethnic differences in weight-related teasing in adolescents. Obesity (Silver Spring) 16, (Suppl. 2) S3– S10. Wertheim, E., Koerner, J., & Paxton, S. (2001) Longitudinal predictors of restrictive eating and bulimic tendencies in three different age groups of adolescent girls. Journal of Youth and Adolescence 30, 69–81. Young-Hyman, D., Schlundt, D.G., Herman-Wenderoth, L., & Bozylinski, K. (2003) Obesity, appearance, and psychosocial adaptation in young African American children. Journal of Pediatric Psychology 28, 463–472. Young-Hyman, D., Tanofsky-Kraff, M., Yanovski, S.Z., et al. (2006) Psychological status and weight-related distress in overweight or at-risk-for-overweight children. Obesity (Silver Spring) 14, 2249–2258. Young, Y. (2009) Online teasing leads to teen’s suicide.

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University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Physical activity programmes in high schools Fiona Brooks Josephine Magnusson

DOI:10.1093/acprof:oso/9780199572915.003.0032

Abstract and Keywords Across the lifespan physical inactivity represents a key risk to health and well-being; the World Health Organization has estimated that physical inactivity is a major contributing factor in over 1.9 million deaths worldwide and a significant risk factor for the majority of cancers and long term conditions. Physical activity is a key component in the maintenance and attainment of healthy weight; as a consequence the reduction of sedentary lifestyles has featured in many countries as an important arm of policies designed to address childhood obesity. This chapter discusses how participation by young people in physical activity should not solely be seen as a means to address current concerns about childhood obesity; instead physical activity can provide a number of positive benefits that contribute to the well-being of young people. Participation in physical activity can offer a plethora of health benefits, not only impacting positively on physiological health and development but also psychological well-being, including having important social benefits. The relationship between physical activity and emotional and psychological well being is also addressed, as physical activity levels have been found to be one of the key health-related outcomes that is associated with overall life satisfaction among schoolaged children. The importance of seeing benefits of activity in context of young people's here and now, rather than having the sole aim of benefiting their future health, has been recognized by the European Heart Health Initiative (2001).

Keywords: lifespan, well-being, physical activity, obesity, children, school, intervention, eating, health promotion, life satisfaction

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Chapter summary Across the lifespan physical inactivity represents a key risk to health and well-being; the World Health Organization has estimated that physical inactivity is a major contributing factor in over 1.9 million deaths worldwide and a significant risk factor for the majority of cancers and longterm conditions. Physical activity is a key component in the maintenance and attainment of healthy weight; as a consequence the reduction of sedentary lifestyles has featured in many countries as an important arm of policies designed to address childhood obesity. This chapter discusses how participation by young people in physical activity should not solely be seen as a means to address current concerns about childhood obesity; instead physical activity can provide a number of positive benefits that contribute to the well-being of young people. Participation in physical activity can offer a plethora of health benefits, not only impacting positively on physiological health and development (WHO, 2004) but also psychological wellbeing (Parfitt & Eston, 2005), including having important social benefits (Brooks & Magnusson, 2006, 2007). The relationship between physical activity and emotional and psychological wellbeing is also addressed in this chapter, as physical activity levels have been found to be one of the key health-related outcomes that are associated with overall life satisfaction among schoolaged children (Aarnio et al., 1997; Thome & Espelage, 2004; Zullig et al., 2001). The importance of seeing benefits of activity in context of young people’s here and now, rather than having the sole aim of benefiting their future health, has been recognized by the European Heart Health Initiative (2001).

Introduction Young people and physical activity participation levels Despite the positive benefits of regular physical activity both immediately and across the life course, a very high proportion of young people and particularly older teenagers do not undertake the generally accepted minimum level of activity required for health and well-being, that of 1 hour moderate to vigorous physical activity per day (MVPA) (Currie et al., 2008). The early school years are distinguished by relatively high levels of physical activity often routinely incorporated into younger children’s daily lives as part of free play. Consequently during the early school years up to about age 11, over 70% of both sexes have been found to regularly participate in sport, exercise, or active play such as ‘running about’ or cycling (Craig & Mindell, 2008). This situation changes dramatically by middle adolescence, so that by age 15 years levels of physical activity are highly gendered. Participation in any sport or exercise has been found to drop by a small percentage between the ages of 11 and 15, but declines much more dramatically for girls across the same period to the point where undertaking sufficient physical activity shifts from a majority (p.381) to a minority of girls (Craig & Mindell, 2008). Significantly this gendered pattern of physical activity levels have been found to operate across Europe and in North America, with boys reporting higher daily moderate to vigorous physical activity rates than girls across all ages during adolescence (Currie et al., 2008). However rather than girls being defined as simply ‘unwilling’ to participate in sports, work that has considered girls drop in sports and physical activity participation during adolescence has highlighted the gendered character of physical activity provision; for example compared to their male peers girls face a limited range of provision designed specifically for them (Brooks & Magnusson 2007; Flintoff & Scraton, 2001). Different access opportunities for boys and girls coupled with negative, often subtle, gender stereotyping from peers and families all serve to reinforce young women

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‘choosing’ sedentary leisure pursuits (Culp, 1998). This pattern of lower involvement in physical activity in girls has been reported globally, but levels of participation vary between countries. The International Health Behaviour in School Aged Children (HBSC) study identified significant variations in young people’s daily MVPA levels between countries in Europe and North America for example in France 14% of 15-year-old boys and only 5% of girls report meeting the recommended daily MVPA level compared to 34% of 15-year-old boys and 14% of 15-year-old girls in the USA (Currie et al., 2008). Corresponding figures from Australia reported that 18% of boys and 12% of girls aged 14–15 years engage in daily MVPA of at least 1 hour (Scully et al., 2007). The exact underlying explanation for such country wide differences is unclear but again highlights the significance of understanding both cultural differences in engagement with physical activity and the impact of different policies on physical activity participation. In addition to country and gender differences in physical activity in young people, it has been suggested that socioeconomic status (SES) may play a part in levels of participation. The research to date suggests that the relationship with family affluence is complex and not universally found, for example, an association has been reported by Currie et al. (2008) between higher levels of family affluence and higher MVPA levels in some European countries (such as Spain, Czech Republic, the Netherlands) as well as Canada (Currie et al., 2008). However a significant association between affluence and MVPA was only found in under half of the 41 countries surveyed (Currie et al., 2008). Research from the UK has reported that girls, but not boys, from lower SES backgrounds tend to be less active (Brodersen et al., 2007), whereas a study of Portuguese adolescents found no relationship between adolescent physical activity and parental education or income (Mota & Silva, 1999). Some find no relationship between physical activity and SES, but report that young people from high SES backgrounds spend less time in sedentary activities than their low SES peers (Scully et al., 2007). Finally, research from the US has shown that schools that serve students from high SES backgrounds provide physical education at a higher frequency and intensity than schools serving lower SES students (Sallis et al., 1996). It is possible that there is an indirect relationship in that adults (parents) from lower SES backgrounds may be less active (Department for Culture Media and Sport (2007) Taking part: The national survey of culture leisure and sport), and there is a relationship between parental and adolescent activity (e.g. Mota & Silva, 1999). Further, as indicated by the research by Sallis et al. (1996) less affluent schools may have different provision for PE than more affluent schools, which again could impact on the physical activity levels of adolescents attending different schools. A review of physical activity interventions suggests that research has insufficiently considered the synergistic opportunities of promoting physical activity across generations or how to sustain engagement among young people and families from lower socioeconomic groups (Marcus et al., 2006). At least part of the reason for these mixed findings are likely to be down to inconsistencies in measures of SES and family affluence, and it is also important to note that SES status is not an absolute value but may mean different things in different countries. (p.382) Sedentary lifestyle choices by young people, such as time spent watching TV or computer gaming leisure activities, are often presented as explanations for reduced activity levels in middle adolescence (BMA, 2003; Smith & Green, 2005). High levels of TV watching has been associated with higher levels of consumption of energy dense foods as well as bullying

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(Crespo, 2001). The hours spent television viewing increases with age during adolescence and gender differences are small, and higher levels of viewing are associated with lower family affluence across Europe but more so in more affluent countries such as Western and Northern Europe (Currie et al., 2008) The relationship between computer gaming and weight status is however less well understood. In contrast to TV viewing younger adolescents tend to report more time spent on computer gaming than 15-year-olds and boys have been found to be much likely to spend 2 or more hours a day on computer games than girls (Brooks et al., 2009); however girls maybe more likely to spend time on social networking sites. However a direct link between youth sedentary activities and reduced participation in physical activity is not proven. Although it seems that sedentary behaviours do appear to contribute to weight status, the casual relationship is less clear (Danner, 2008; Fleming-Moran & Thiagarajah, 2005). Sedentary behaviours may be leading to higher consumption of energy dense foods or replacing physical activity, either by being a choice by young people or because young people’s social context allows for few alternatives. The differences between just two forms of sedentary behaviours: computer gaming and television viewing highlight the importance of understanding the meaning of such activities to young people in order to determine the relationship between such activities and physical activity participation rates. Overall the simple equation of lower activity rates with young people’s sedentary lifestyle choices singularly fails to examine the way that gender, socio-economic, cultural, and environmental characteristics also determine young people’s activity levels. A central argument proposed in this chapter is that even school based interventions are only likely to be effective if they take account of socio-cultural and economic factors as determinants of physical activity. If education interventions fail to encompass such socio-cultural understandings they may simply serve to reinforce inequities, for example by increasing girls’ lack of body confidence and reinforcing a negative attitude to physical activity. Gaining a better understanding of the meaning of activities from young peoples’ perspectives is also likely to assist with the development of more effective programmes.

The role of schools A strategy adopted in many countries to address inactivity among young people has been to look to education establishments as appropriate sites for the provision and fostering of physical activity programmes. Schools have long been identified as having the right infrastructure, equipment, and expertise to provide an immediate increase in activity levels as well as potentially being able to encourage commitment to active lifestyles among youth (Stone et al., 1998). In the developed world at least, most children and young people attend school and interventions implemented here. They therefore have the potential to reach a large number of people who are, in effect, captive audiences. As the schools already serve the function of teaching young people skills that they will need for the future, providing knowledge and teaching on subjects that will promote their health is seen by many as an integral part of teaching them how to look after themselves both for immediate well-being and in preparing them for adulthood. In some countries concerns over rising obesity levels among the young and the resulting increased burden of disease among future adult generations stimulated policies intended to reverse the squeezing of physical education within the curriculum and set targets for minimum levels of physical education provision, for example, in (p.383) the UK there is now

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a Public Service Agreement that has set out to ensure that by 2010 all children have 2 hours curriculum timetabled physical education and the opportunity to access a further 2–3 hours of sport beyond the curriculum per week. The European Heart Health Initiative (2001) was developed as a response to the increasing levels of overweight and obesity, and the decreasing time spent in school physical education among children in member countries. It stresses the importance of a regulated minimum period of time devoted to physical education and recommends a statutory 3-hour minimum per week in schools. It further very strongly promotes the idea that any physical activity initiatives implemented in schools need to take young people’s perspectives and views into account in order that programmes are developed that meet their needs. In particular, the views of girls and young women need to be sought. As noted earlier this is the group for whom levels of activity drop most dramatically during the adolescent years. It further demands an improvement in both the quantity and quality of PE provision, and quotes evidence to show that poorly delivered PE programmes that do not meet young people’s needs may deter individuals from participating in physical activity for life. In 2004, the World Health Organization (WHO) published the Global Strategy on Diet, Physical Activity and Health, with the objectives to reduce risk factors for non-communicable diseases such as poor diets and physical inactivity; to increase awareness of benefits of healthy lifestyles; to encourage development and implementation of policies and action plans to improve diets and physical activity levels; and to monitor scientific data and key influences on diet and physical activity. Schools were identified as a particularly important setting for implementing these goals among children, as they ‘influence the lives of most children in all countries’ and should provide an environment that is beneficial to the health and development of the children in their care. This includes a recommendation for daily provision of physical education.

Existing programmes Many countries have in recent years implemented programmes that have directly sought to capitalize on the potential that school based actions offer to directly impact on young people’s physical activity levels, such as the ‘Healthy Schools’ initiative (McGinnis & DeGraw, 1991; Nutbeam, 1992). Healthy schools initiatives are intended to operate within a whole school framework, in which health and well-being becomes the responsibility of the school and is embedded across the activities of the school. In the UK this includes setting minimum recommended hours for physical education and providing healthy options in terms of food. Although these programmes have as an aim to promote the general health and well-being of young people, one step along from this are more intensive initiatives and interventions targeted strongly and specifically at improving physical fitness and to prevent and/or reduce obesity. Such focused initiatives often employ a multi-faceted approach depending of the specific goals and target outcomes, but usually include educational materials and school-level activities aimed at getting students more involved in healthy behaviours such as physical activity. Interventions aimed at increasing physical activity among children and young people tend to have mixed results. Generally, improvements in knowledge and attitude scores are noted among intervention groups, whereas effects on self-reported or objectively measured physical activity and physical indices such as BMI are mixed. Varying results are also found for different ages,

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and for boys and girls. One study that used a ‘buddy-system’ whereby older children acted as ‘healthy buddies’ for younger children as a form of peer education on healthy behaviours generated greater changes in health behaviour scores (e.g. physical activity) among the peer educators and among their female, but not male, younger buddies (Stock et al. 2007). It is known that peer (p.384) education schemes in varying areas of health education tend to have a greater positive impact on the (usually older) peer educators than on the children they are educating. Girls are less active than boys overall, and tend to drop off in their levels of activity to a greater extent than boys as they get older, which may be the reason any effects often are greater for girls than for boys. Alternatively, it may be that girls need greater support and reinforcement for physical activity than do boys, and that physical activity interventions provide this support. Traditional PE in many countries also tend to be geared towards activities that are more boy-oriented, such as team sports that girls may resist as not fitting with their interests (Brooks & Magnusson, 2007), which means that any changes to the PE curriculum, especially those that encourage cooperation and participation above competition and performance may be favoured by girls more strongly than boys. In accordance with the idea of the school as an arena for health promotion to a captive audience comprising the majority of young people, most interventions tend to target the whole population of young people, and many do not look at effects separately for boys and girls or respond to diversity among young people. Among those that do, one dance-based intervention programme targeting ethnic minority students in the US (Flores, 1995) found positive effects for girls in terms of decreased BMI and positive attitudes towards physical activity. No effect was found for boys, and even an indication of somewhat more negative attitudes towards physical activity was noted among boys in the intervention group following the programme. However it has been suggested that some non-sporting boys can value an emphasis within physical education that moves away from competitive successes and displays of masculine prowess to a more facilitative skills based programme (Brooks & Magnusson, 2006; Robertson, 2003). This is perhaps an indication of the need to ensure that any programmes that are implemented are developed in collaboration with young people to ensure that they are gender-appropriate and acceptable. In studies where gender has been addressed separately, it is girls that tend solely to be the focus. This is largely because of the more dramatic drop-off in physical activity among adolescent girls than boys, and because of the lower PA participation rates overall among girls, yet how to create inclusive programmes that benefit both male and female young people who perceive themselves as excluded and marginalized by current provision warrants further examination. Among specific interventions aimed at girls, ‘New Moves’ (Neumark-Sztainer et al., 2003), aimed to bring about positive changes in eating and exercise behaviours among high school girls, in order to promote healthy weight as well as discourage unhealthy weight management behaviours. This programme is outlined in this book in Chapter 20. An additional aim of the programme was to support body image and well-being. The programme targeted non-overweight as well as overweight girls, and consisted of daily sessions of which four sessions per week were structured around physical activity. This component focused on life-long activities in a supportive and non-competitive environment. Evaluation of the programme suggests that it was successful in terms of acceptability and in fostering positive attitudes towards physical activity in the girls that participated. Changes were also noted in positive shifts along the stage of change continuum for physical activity; however no significant differences between intervention and control groups were seen for changes in BMI. There is also variation in obesity/overweight

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and physical activity participation among different ethnic groups. The majority of studies that have targeted specific ethnic groups have been carried out in the US. Johnston et al. (2007) developed a programme aimed at Mexican American children, who are known to have higher incidence of obesity than white American children. It combined health and nutrition education with behavioural techniques, with a strong focus on physical education. An intensive programme was delivered with daily interventions for the first 12 weeks (one health education, four PE lessons per week), giving individual support to students who failed to participate or to lose weight. It is unclear if the physical education component was culturally adopted; dietary advice focused on how to make healthier (p.385) traditional Mexican food (with family involvement), and significant differences were found between baseline and follow-up in BMI. A review of the effectiveness of physical activity interventions for young people, almost all of which were school based (van Sluijs et al., 2007), however found only inconclusive evidence of effectiveness of interventions targeting girls only and no evidence of positive effects on physical activity involvement in studies targeting ethnic minority students. At this stage, it would appear that interventions that target girls may be well liked by the target population, which should be seen as a positive outcome in itself (especially as girls show a strong dislike of traditional PE) even if the effect on weight loss is insignificant. It is possible that very intensive programmes that provide a lot of individual support may be more effective, but it is doubtful how likely these are to be sustained after the research component of a programme ends, especially in a school environment where physical activity is already being pushed out of the curriculum. Another review (Dobbins et al., 2009) addressed the effectiveness of school-based programmes to promote physical activity on lifestyle health behaviours (physical activity participation, sedentary behaviour) and physical health measures (blood cholesterol, VO2 max, body mass index (BMI)). It was found that such programmes can have an effect on the duration of time spent in physical activity, particularly during school hours, but do not lead to greater levels of activity outside of school in either children or adolescents. The effects for participation in school were noted more strongly among children than in adolescents, and were greater for interventions of longer duration, indicating that such programmes perhaps need to be sustained over a period of time (minimum of 18 weeks) to have noticeable effects. Mode of delivery may play an important role in that studies that used specialist PE teachers appeared to be more successful than those using non-specialist teachers. Further, the review concluded that a reduction in television viewing (used as a marker of sedentary behaviours) also appears to be an effect of school-based physical activity interventions in children, but less so in adolescents. With regard to physical health measures, there appears to be a strong positive effect on blood cholesterol levels and VO2 max (particularly among adolescent girls), but minimal impact on BMI. Common for all studies that reported positive impacts of interventions were, at a minimum, use of printed educational materials and changes to the school curriculum to accommodate healthy changes. It appears that multi-component programmes are more effective, and that linking in with community-based initiatives may be beneficial. Pyle et al. (2006) suggested that successful interventions should also include behaviour management strategies such as selfmonitoring, stimulus control, and operant conditioning.

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Key aspects of effective interventions Based on the earlier, it would appear that in order for school-based programmes that address participation in physical activity to be successful, they need to provide intensive long-term interventions that have the ability to engage with individual students and respond to their individual needs. This is in line with a recognition that several different socio-cultural factors impact on involvement in physical activity in young people, and that reasons for choosing not to take part vary according to those factors. When young people are asked for their views on how to improve provision of PE in school and those recommendations are adhered to, participation and enthusiasm for physical activity increases and may impact positively on confidence and commitment to participate in out-of-school activity as well (Brooks & Magnusson, 2006). Further, interventions undertaken in school that are not isolated from the school environment but link with the community, and take family and friendship factors into account may also better address the needs of young people, and young women in particular (Coleman et al., 2008). A shift away from the (p.386) needs of the school (e.g. having successful school teams that win tournaments) to the needs of the individual is necessary if more young people are to actively engage with physical education and activity.

Conclusions Increasing physical activity levels among young people represents a popularized ‘common sense’ strategy to reduce childhood obesity. However, the establishment of a direct linear relationship between physical activity interventions and reductions in obesity prevalence remains difficult to establish. Currently the evidence base suggests that at best, demonstrable impact on obesity resulting from physical activity programmes is likely to be small, although many interventions tend to be short-term ‘pilots’ and therefore the potential for any longer-term benefits such as sustained commitment to sports participation remain unknown. Programmes that are implemented in schools should be developed in collaboration with the young people that the interventions are aimed at, to ensure that they meet their needs and are seen to be acceptable. The differing interests and preferences of boys and girls should be taken into account, but although girls are traditionally seen as the group that is more difficult to engage, participation in physical activity and ‘sports’ should not be assumed to be unproblematic for boys. Irrespective of demonstrable impacts on obesity prevalence physical activity can for young people act as a protective health asset that offers positive impacts on health and well-being. Essentially delineating physical activity programmes by their impact on obesity devalues and marginalizes the plethora of health related benefits that can be derived from participation in physical activity. The central tenet underpinning this chapter has been to illuminate that the question ‘how can participation in physical activity impact on obesity?’ is essentially misplaced, in so far as it constrains the way that physical activity programmes can be evaluated and developed. Instead physical activity programmes could offer a significant impact on health related behaviours by focusing on how to achieve and sustain access to inclusive physical activity interventions that young people themselves define as valuable. In this way by moving from adult-led obesity agendas that primarily attend to young people in relation to their future adult health, it is action to improve the current well-being of young people that can be given primacy. References Bibliography references:

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Aarnio, M., Kujala, U.M., & Kaprio, J. (1997) Associations of health-related behaviors, school type and health status to physical activity patterns in 16 year old boys and girls. Scandinavian Journal of Social Medicine 25(3), 156–167. BMA (2003) Adolescent health. British Medical Association Board of Science and Education, London. Brodersen, N.H., Steptoe, A., Boniface, D.R., & Wardle, J. (2007) Trends in physical activity and sedentary behaviour in adolescence: ethnic and socioeconomic differences. British Journal of Sports Medicine 41, 140–144. Brooks, F. & Magnusson, J. (2006) Taking part counts: adolescents experiences of the transition from inactivity to active participation in school based physical education. Health Education Research. Available on line May 2006. Brooks, F. & Magnusson, J. (2007) Physical activity as leisure: the meaning of physical activity for the health and well-being of adolescent women. Health Care For Women International: Special Edition, Health and Leisure 28(1), 69–87. Brooks, F., van der Sluijs, W., Klemera, E., et al. (2009) Young people's health in Great Britain and Ireland: findings from the health behaviour in school-aged children survey, 2006. HBSC International Coordinating Cent, Edinburgh. Coleman, L., Cox, L., & Rocker, D. (2008) Girls and young women's participation in physical activity: psychological and social influences. Health Education Research 23, 633–647. Craig, R. & Mindell, J. (Ed.) (2008) Health survey for England 2006, vol. 2, obesity and other risk factors in children. The Information Centre, Lifestyle Statistics, London. Crespo, C. (2001) Television watching, energy intake and obesity in US children. Archives of Paediatric and Adolescent Medicine 155, 360–365. Culp, R. (1998) Adolescent girls and outdoor recreation: a case study examining constraints and effective programming. Journal of Leisure Research 30(3), 356–379. Currie, C., Nic Gabhainn, S., Godeau, E., et al. (2008) Inequalities in young people's health. HBSC International report, from the 2005/6 survey. WHO Regional Office for Europe, Copenhagen. Danner, F. (2008) A national longitudinal study of the association between hours of TV viewing and the trajectory of BMI growth. Journal of Pediatric Psychology 33(10), 1100–1107. DCMS (2007) Taking Part: The National Survey of Culture, Leisure and Sport. London: Department for Culture, Media and Sport. Dobbins, M., DeCorby, K., Robeson, P., Husson, H., & Tirilis, D. (2009) School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6-18. Cochrane Database of Systematic Reviews 2009(1): Art. No.: CD007651.

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European Heart Health Initiative (2001) Children and young people: the importance of physical activity. Brussels, European Heart Network. Fleming-Moran, M. & Thiagarajah, K. (2005) Behavioural interventions and the role of Televison in the growing epidemic of adolescent obesity. Methods of Information in Medicine 44, 303–309. Flintoff, A. & Scraton, S. (2001) Stepping into active leisure? Young women's perceptions of active lifestyles and their experiences of school physical education. Sport, Education and Society 6(1), 5–21. Flores, R. (1995) Dance for health: Improving fitness in African American and Hispanic adolescents. Public Health Reports 10(2), 189–193. Johnston, C.A., Tyler, C., Fullerton, et al. (2007) Results of an intensive school-based weight loss program with overweight Mexican American children. International Journal of Pediatric Obesity 2, 144–152. Marcus, B., Williams, D., Dubbert, P., et al. (2006) Physical activity intervention studies: what we know and what we need toknow: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity); Council on Cardiovascular Disease in the Young; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation 114(24), 2739–2752. McGinnis, J. & DeGraw, C. (1991) Healthy schools 2000: creating partnerships for the decade. Journal of School Health 61(7), 292–297. Mota, J. & Silva, G. (1999) Adolescents’ physical activity: Association with socio-economic status and parental participation among a Portuguese sample. Sport, Education and Society 4(2), 193– 199. Neumark-Szteiner, D.M., Story,Hannan, P.J., & Rex, J. (2003) New Moves: a school-based obesity prevention program for adolescent girls. Preventive Medicine 37, 41–51. Nutbeam, D. (1992) The health promoting school: closing the gap between theory and practice. Health Promotion International 7(3), 151–153. Parfitt, G. & Eston, R.G. (2005) The relationship between children's habitual activity level and psychological well-being. Acta Paediatrica 94, 1791–1797. Pyle, S.A., Sharkey, J., Yetter, G., Felix, E., Furlong, M.J., & Poston, W.S.C. (2006) Fighting and epidemic: the role of schools in reducing childhood obesity. Psychology in the Schools 43(3), 361–376. Robertson, S. (2003) 'If I let a goal in, I'll get beat up': contradictions in masculinity, sport and health. Health Education Research 18(6), 706–716.

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Sallis, J.F., Zakarian, J.M., Hovell, M.F., & Hofstetter, C.R. (1996) Ethnic, socioeconomic, and sex differences in physical activity among adolescents. Journal of Clinical Epidemiology 49(2), 125–134. Scully, M., Dixon, H., White, V., & Beckmann, K. (2007) Dietary, physical activity and sedentary behaviour among Australian secondary students in 2005. Health Promotion International 22(3), 236–245. Smith, A. & Green, K. (2005) The place of sport and physical activity in young people's lives and its implications for health: some sociological comments. Journal of Youth Studies 8(2), 241–253. Stone, E., McKenzie, T.L., Welk, G.J., & Booth M.L. (1998) Effects of physical activity interventions in youth review and synthesis. American Journal of Preventive Medicine 15(4), 298–315. Stock, S., Miranda, C., Evans, S., et al. (2007) Healthy Buddies: a novel, peer-led health promotion program for the prevention of obesity and eating disorders in children in elementary school. Pediatrics 120, e1059–e1068. Thome, J. & Espelage, D. (2004) Relations among exercise, coping, disordered eating and psychological health among college students. Eating Behaviours 5(4), 337–351. van Sluijs, E.M.F., McMinn, A.M., Griffin, S.J. (2007) Effectiveness of interventions to promote physical activity in children and adolescents: systematic review of controlled trials. BMJ 335, 307–315. WHO (2004) Global strategy on diet, physical activity and health. Geneva, World Health Organization. Zullig, K., Valois, R., Huebner, S., Oeltmann, J., & Drane, J. (2001) Relationship between percieved life satisfaction and adolescents' substance abuse. Journal of Adolescent Health 29(4), 279–288.

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Effective school meal interventions: Lessons learned from Eat Well Do Well in Hull, England

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Effective school meal interventions: Lessons learned from Eat Well Do Well in Hull, England Derek Colquhoun Jo Pike

DOI:10.1093/acprof:oso/9780199572915.003.0033

Abstract and Keywords It is a truism to suggest that obesity has emerged as one of the most significant issues for public health policy in the last 10 years. Globally, an estimated 1.2 billion people are classified as overweight, of whom 300 million are categorized as obese. In 2004 when Eat Well Do Well was developed and introduced in the UK, around 10% of children aged 6–10 years were classified as obese. In addition, according to the Department of Health (2006) 36.6% of children in Hull were estimated to be living in poverty compared to the national average of 21.3%. This chapter presents a description and evaluation of the lessons learned from the Eat Well Do Well program, which was delivered between 2004 and 2007 by the Kingston-Upon-Hull City Council in England. This was an ambitious, innovative and exciting programme which provided all children (approximately 25,000 school children) in seventy-four primary and special schools access to free school meals which may have included healthy breakfasts, hot lunches/dinners, fruit up to Key Stage 2 (ages 11/12), and after school snack. The evaluation of Eat Well Do Well considered ‘what worked’ from the perspectives of the major stakeholders: the children, parents, caterers and schools. The chapter discusses several characteristic features of the program such as addressing health inequalities, complexity and whole of system change, and developing a spatial imagination. It presents some of the difficulties encountered including the problems associated with school meals as a political project, school meals as a service intervention, and how to relate Eat Well Do Well to other projects in schools.

Keywords: nutrition, education, eating, health promotion, physical activity, school meals, Hull, Eat Well Do Well

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Effective school meal interventions: Lessons learned from Eat Well Do Well in Hull, England

Chapter summary It is a truism to suggest that obesity has emerged as one of the most significant issues for public health policy in the last 10 years. Globally, an estimated 1.2 billion people are classified as overweight, of whom 300 million are categorized as obese (Butland et al., 2007). In 2004 when Eat Well Do Well was developed and introduced, around 10% of children aged 6–10 years were classified as obese. In addition, according to the Department of Health (2006) 36.6% of children in Hull were estimated to be living in poverty compared to the national average of 21.3%. This chapter presents a description and evaluation of the lessons learned from the Eat Well Do Well programme, which was delivered between 2004 and 2007 by the Kingston-Upon-Hull City Council in England. This was an ambitious, innovative, and exciting programme which provided all children (approximately 25,000 school children) in 74 primary and special schools access to free school meals which may have included healthy breakfasts, hot lunches/dinners, fruit up to Key Stage 2 (ages 11/12) and after school snack. The evaluation of Eat Well Do Well considered ‘what worked’ from the perspectives of the major stakeholders: the children, parents, caterers, and schools. This chapter discusses several characteristic features of the programme such as addressing health inequalities, complexity and whole system change, and developing a spatial imagination. Finally, some of the difficulties encountered are presented and discussed including the problems associated with school meals as a political project, school meals as a service intervention, and how to relate Eat Well Do Well to other projects in schools.

Introduction The national context for school meals in England There has been an exponential rise in the number of public health initiatives across the globe that attempt to treat and prevent childhood obesity. Most of these initiatives address lifestyle factors (mainly over-nutrition/eating and a lack of exercise). With this in mind there has been a focus specifically on what children eat at school. It would be fair to say that many issues facing schools in their attempts to provide healthy school meals have been impacted on by the challenges facing schools since the mid-1980s. At this time Margaret Thatcher and her conservative government removed nutritional standards for school food and introduced compulsory competitive tendering for school catering services. They also introduced a national curriculum, which focused on literacy, numeracy, and science, which meant that home economics as a school subject withered and became less popular with children and teachers alike. Finally, schools began to use their canteen (p.390) and kitchen for other activities leading to a removal of kitchens and kitchen equipment from most schools. These legislative changes and challenges were introduced throughout the 1980s and 1990s (see for example, the 1980 Education Act (HMSO, 1980), 1986 Social Security Act (HMSO, 1986) which removed entitlement to free school meals and constant modifications to the national curriculum throughout the 1990s) so the recent focus on healthy school food by the present government was welcomed by many health and welfare professionals (we acknowledge the introduction of healthy school food was also challenging for many school communities, especially school caterers). Eat Well Do Well Between 2004 and 2007 Kingston-Upon-Hull City Council in England embarked on an ambitious, innovative, and exciting programme (called Eat Well Do Well) which provided all children

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(approximately 25,000 school children) in 74 primary and special schools access to free school meals which may have included healthy breakfasts, hot lunches/dinners, fruit up to Key Stage 2 (ages 11/12) and after school snack. Nationally guidance for school meals comprised minimal standards based on food groups. However, Eat Well Do Well used guidelines established by the Caroline Walker Trust (1992), which determined that school meals should be based on children’s recommended daily nutrient intake. Hull City Council was the first council in England to implement nutrient based standards. The Department of Learning and Culture within the City Council worked in partnership with the two Primary Care Trusts (PCTs) in the city to develop and implement the initiative. The programme was approved by the national Schools Standards Minister who supported the programme through his special ability and ‘Powers to Innovate’ under Section 2 of the Education Act 2002 to suspend the relevant sections of the Education Legislation (section 512 of the Education Act 1996) that prohibit councils from providing meals and refreshments free to those children who are not eligible for free meals. A major underlying principle of the programme was the relationship between healthy eating and academic attainment. However, by far the major justification of Eat Well Do Well was that it would address health inequalities across the city (Hull City Council, 2004). In addition to the provision of free healthy school lunches, breakfasts, and after school refreshments, Hull City Council became the first council in the country to extend the provision of free fruit and vegetables under the National School Fruit and Vegetable Scheme (NSFVS) to Key Stage 2 children. The NSFVS is part of the government’s 5 A DAY programme, which is jointly funded by the Department of Health and the Big Lottery Fund and provides a free piece of fruit or a vegetable to children aged 4–6 years on each school day. The scheme was rolled out in phases across the country and was implemented locally in autumn 2004. Nationally, current provision extends only to those children in Key Stage 1. However, Hull City Council extended this provision so that all primary school children were offered a free piece of fruit or a vegetable on each school day. Typically children received bananas, pears, apples, satsumas, strawberries, cherry tomatoes, or carrots. Schools joined Eat Well Do Well on a structured 6 weekly basis (every half term) and implemented the programme in a way phased approach that suited them so that all schools were engaged in the scheme by February 2005. Lessons we learned from Eat Well Do Well There are many interventions across the globe in the area of school meals. It would be fair to say that none of them possesses all the characteristics of a successful school meal intervention. (p. 391) However, the Eat Well Do Well programme had many features that would be worth sharing. Later in this chapter, we also share those features, which didn’t work so well! The evaluation of Eat Well Do Well considered ‘what worked’ from the perspectives of the major stakeholders: the children, parents, caterers, and schools. However, due to a limitation of space we will address generic features of the successful implementation of Eat Well Do Well across the city. The evaluation, which was co-ordinated through the Institute for Learning at the University of Hull, collected data from a variety of sources: children, parents, teachers, head teachers,

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caterers, cooks, and school staff and used a variety of methods: interviews, focus groups, surveys, experiential methods with children such as the production of DVDs of their lunchtime experiences, mapping of school dining rooms, use of modelling clay with younger children, and nutritional analysis of the food a small sample of children consumed at lunchtime. Addressing health inequalities

The first point to make is that Eat Well Do Well was considered to be a very successful intervention by the evaluation team. As we have shown elsewhere (Colquhoun et al., 2008; Pike & Colquhoun 2009), Eat Well Do Well successfully tackled the poor nutrition of primary age children in the city. Uptake of the school meals (a measure of the impact of Eat Well Do Well), doubled from the start of the programme to its end 3 years later. Indeed, Eat Well Do Well was seen to be an important way of addressing health inequalities across the city. It did this by reducing the nutritional difference between those children who were eligible for free school meals at the start of the programme with those who were not; that is, it reduced the health gradient between these groups of children. This has been significant and an important avenue for policy development by the current Labour government. There are many other indicators of success and these are illustrated in the final evaluation report at www.hull.ac.uk-research. Complexity and whole of system change

As we mentioned earlier, Eat Well Do Well was a highly complex intervention. The intervention itself was different in different schools (some schools implemented free healthy breakfasts initially whereas others did the free healthy lunches; others still did the free healthy after school snack – and of course any combination of these!). Of course it could be argued that this flexibility ensured that schools would implement parts of the programme that were most important and relevant to them and this was often the case. Indeed, the evaluation didn’t set out the measure the degree of ‘fidelity’ of Eat Well Do Well across the city. The evaluation team viewed this complexity as an important and necessary feature of school based interventions especially where an intervention is being implemented across whole systems such as in the case of Eat Well Do Well and where schools could tailor the intervention to suit the social, cultural, and economic characteristics of their families. There is no doubt that this degree of flexibility in the way schools engaged with Eat Well Do Well led to its eventual success. Developing a spatial imagination

Schools that possessed what we have come to term a ‘spatial imagination’ (Pike & Colquhoun, 2009) seemed to engage more successfully with Eat Well Do Well. By spatial imagination we mean that schools were able to capture, harness, and exploit the full potential of the physical space, boundaries, and relationships in existence in the school dining room. As Pike & Colquhoun (2009) have commented, the dining room aesthetics (e.g. light, airiness, lack of noise, and little disruptive/unnecessary movement) contributed significantly to the dining experience felt by all using the dining room. This simple point cannot be overestimated. In England at least, the school dining room has often been the ‘forgotten space’ within schools while the attention of politicians, (p.392) policy makers, and educators more generally has been focused on activities within the physical boundary of the classroom. Allied to the spatial imagination in relation to the dining room we also need to consider the physical use of space and how it was and wasn’t used for other features of a successful dining

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experience. Queuing for instance, has been a major concern for many schools. Often it’s in the queue where a lot of disruption, noise, and behaviour problems often occur. Successful schools have recognized this and now have in place a shortened queuing system, pictures of the meals/ food for children to choose from as they queue, different year levels queuing at different times on a rotation basis, and even children acting as monitors/buddies to ‘police’ the queue freeing the adult supervisors to assist children eating their dinners. The food counter has often been a source of frustration, particularly for younger/smaller children. Because of the physical layout of the food server and the food warmers often these younger and smaller children can’t see the food on offer. Some schools have recognized this and created a ‘ramp’ for the younger children to be able to see what food is available. This small change in parallel with the pictures of the food and menus visible from the queue has meant that children arrive at the food counter much more able to make an informed decision about the food they would like to eat. The active involvement of children in these features was an important aspect of a successful programme. As Colquhoun et al. (2008: 94) have commented about the children at Langley Primary School1 in the city: In order to overcome this problem (of slow queues) the school developed a menu display board. This was done during ICT lessons with a year 6 group (10–11 year olds). The children were asked to design the menu display using written words and pictures. The menus were then laminated and displayed on a flipboard outside the dining room where children pick up their dinner plates. Consequently, children were able to think about what they wanted for lunch while waiting in the queue and this resulted in less time spent queuing and less congestion in the dining room. Pictures of menu items were also displayed above the counter and changed on a daily basis by breakfast club attendees. This further informed children about their lunch options providing an image of the food to ensure that access to menu information was not dependent on reading ability. Children felt that there was a sense of ownership in the dining room. They had renamed their dining room ‘Langley Cool Café’ and a sign was displayed on the door. Children in year 5 (9–10 year olds) commented that this helped to deliver an important message that the dining room was ‘their’ space. Other schools according to Colquhoun et al. (2008: 97) also involved children creatively in their dining experience, often through their school council: This school encouraged children to try new foods, often tasters would be available for children to try something new … The school council often discussed the food options available and, following a suggestion by the council, the school made available vegetable soup as a starter in winter. This school purchased colourful dishes on which to serve the food instead of using large institutional trays. A significant feature of successful schools is that they have adults eating with the children in the dining rooms. Usually these adults are teaching related staff (teachers and/or classroom assistants) and it is clear they have more positive perceptions of the impact of healthier eating on children if they do eat in the dining room with the children. Middlebank primary school in

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Hull introduced an important innovation to Eat Well Do Well that encouraged what we called ‘seamless provision’ (p.393) of school meals, which meant the transition from curriculum time to dinner time was effortless and caused little disruption, especially at this school as the following except from Colquhoun et al. (2008: 97) illustrates: In the early stages of the project evaluation observations revealed that there were considerable problems with discipline in this school dining room. This was already acknowledged by the head teacher and by lunchtime staff including dinner ladies and cooks. The school embarked on a process of lunchtime reorganisation, whereby teachers were encouraged to eat with the children in the dining room to maintain discipline and to socialise with children around the table. In order to achieve this the lunchtime period was included as part of the school day so that teachers did not have to give up their own time to sit and eat with the children. Teachers still had an equivalent lunch break, but this was staggered so that their break might come before or after the children’s lunchtime. This ensured that over the lunch period in the dining room teachers were available to supervise children. This supervision started in the classroom where children were encouraged to wash their hands and to line up in the class. The whole class then walked down to the dining room together. The class lined up outside the dining room and the lunchtime supervisors would allocate six children to each table. Once seated, children remained at the table until they were told to approach the counter. Bread and water were provided on the table so that children could help themselves when they wished. Tables were also laid with plates and cutlery and this helped to add to a restaurant style atmosphere. Crucial to this was the incorporation of the lunchtime into the school day so that lunchtime practices began in the classroom and carried through into the dining room. (Colquhoun et al., 2008: 97) The other significant adults in the dining room – the lunchtime supervisors (sometimes and inaccurately called ‘dinner ladies’), played an important role in encouraging the children to eat their lunches. The role of the lunchtime supervisor was to assist the children with their lunches (cutting up difficult pieces of food for the younger children), tidying the dining room, and ensuring a safe environment for the children to eat their meal. The evaluation team recognized the importance of these adults to children’s healthier eating and recommended to Hull City Council that they develop a training programme covering the role of the lunchtime supervisor, healthier eating, behaviour management and creating a supportive dining room experience (see Pike, 2008; Pike & Colquhoun, 2010). Of course, it was important to link this training to developments in school improvement and in particular in England to the new Ofsted inspection framework, which included qualitative and quantitative indicators of children’s well-being (see http://ofsted.gov.uk/). What we learned that didn’t work so well School meals as a political project

There were three inter-related features of Eat Well Do Well that in our view could have been improved. The first is that there was a significant political imperative for the Labour Council in the city to address the many social, health, economic, and educational issues facing residents across the city. In 2004 when Eat Well Do Well was introduced Hull City Council faced many

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issues (as outlined in its Comprehensive Performance Assessment – see www.hull.gov.uk) and the timeline from programme conception by councillors and council officials to implementation by school communities and caterers was very short. Indeed, this undue haste was responsible for many schools not implementing the full programme of breakfast, mid-morning fruit, lunch, and after school snack for at least a year. The capacity of schools to cater for more children eating healthier lunches in school was challenged (e.g. physical capacity such as ovens, machines, and pleasant dining rooms) as were the skills of cooks who, for the previous 20 years, had been de-skilled. This capacity problem will be faced by many schools if the government introduces free healthy lunch to all primary age children in the country. (p.394) School meals as a service intervention

The second major issue facing the successful implementation of Eat Well Do Well was that the programme was seen by many as simply a ‘service intervention’ with little integration across the curriculum or indeed even located within a whole school approach. Even though the whole school approach was adopted by many schools for their Healthy School activities, but possibly as a result of the undue haste mentioned earlier, there was little sense that schools could go beyond seeing Eat Well Do Well as something more than the provision of a service at lunchtime. As a result, between 2004 and 2007 council officials were almost permanently in a state of ‘catch up’ trying to encourage schools to include healthier eating within their curriculum, support parents to take up the healthier eating ‘message’, and involve children in decisionmaking, menu design, and meal composition. Of course, healthy eating was part of the personal, social, and health education curriculum but our point is that there was little special emphasis on curriculum links with Eat Well Do Well. Relating Eat Well Do Well to other projects in schools

The third and final feature of Eat Well Do Well that didn’t work as well as it could have is that it wasn’t really related to other healthier eating projects such as the National Healthy Schools Programme or ‘Shape Up’ (see www.hull.ac.uk/Ifl-research). Schools in Hull have been very successful adopting Healthy Schools and many schools have also been engaged in other projects designed to address the structural determinants of obesity. However, because of the two problems outlined earlier – that Eat Well Do Well was seen as a ‘service intervention’ and that it wasn’t integrated across the curriculum and whole school communities – the third problem – the lack of any formal (or even informal relationship) with other projects was problematic (we are conscious that this may be seen as ‘teacher bashing’ but that is not our intention!). Clearly, with hindsight, if Eat Well Do Well were to be re-introduced now or in the future it would be a very different programme. We need to remind ourselves that Hull City Council was the first council anywhere in the UK to introduce such a programme across the whole city and as such encountered (and solved) many pioneering issues.

Conclusions Eat Well Do Well in many ways was a project ahead of its time. Introducing a whole of system change across an entire city in a short time frame was an incredible challenge. Unfortunately, because Eat Well Do Well stopped after 3 years it is difficult to comment on the long-term impact of Eat Well Do Well on health measures such as obesity. However, because of the flexibility inherent in working across a whole system, school communities managed to introduce Eat Well Do Well in a way that was meaningful to them. Because of this they were able to reap

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Effective school meal interventions: Lessons learned from Eat Well Do Well in Hull, England

the benefits of the city council’s pioneering and innovative approach to helping families across the city and reducing the disadvantage gap experienced by many children. Significantly, by doing so they also created a more supportive learning environment for all primary age children in the city. References Bibliography references: Butland, B., Jebb, S., Kopelman, P., et al. (2007) Foresight tackling obesities: future choices project report. HMSO, London. Caroline Walker Trust. (1992) Nutritional guidelines for school meals: report of an expert working group, The Caroline Walker Trust, London. Colquhoun, D., Wright, N., Pike, J., & Gatenby, L. (2008) Evaluation of Eat Well Do Well, Kingston upon Hull’s school meal initiative, University of Hull, Kingston Upon Hull. Department of Health (2006) Community health profile for city of Kingston Upon Hull. Available at , [Date accessed 1 December 2009]. Hull City Council (2004) Report to Cabinet, 20th July, Kingston Upon Hull City Council, Kingston Upon Hull. HMSO (1980) The Education Act, 1980, HMSO, London. HMSO (1986) The Social Security Act, 1986, HMSO, London. Pike, J. (2008) Foucault, space and primary school dining rooms, Children’s Geographies 6(4), 413–422. Pike, J. & Colquhoun, D. (2009) The relationship between policy and place: the role of school meals in addressing health inequalities. Health Sociology Review 18(1), 50–60. Pike, J. & Colquhoun, D. (2010) Embodied childhood in the health promoting school. In K. H˝orschelmann & R. Colls, R. (Ed.) Contested bodies of childhood and youth, Basingstoke: Palgrave Macmillan. Notes: (1) The name of the schools cited in this chapter have been changed for anonymity.

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Effective school meal interventions: Lessons learned from Eat Well Do Well in Hull, England

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Obesity prevention interventions for early childhood: An updated systematic review of the literature

University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Obesity prevention interventions for early childhood: An updated systematic review of the literature Kylie Hesketh Karen Campbell

DOI:10.1093/acprof:oso/9780199572915.003.0034

Abstract and Keywords A previous review of the small number of early childhood obesity prevention literature promoted healthy eating, physical activity, and/or reduce sedentary behaviours in 0–5 year olds, suggesting that this is a new and developing research area. This chapter reviews rapidly emerging evidence in this area and assesses the quality of studies reported. Ten electronic databases were searched to identify literature published from January 1995 to August 2008. Inclusion criteria were interventions reporting child anthropometric, diet, physical activity or sedentary behaviour outcomes, and focusing on children aged 0–5 years of age. Exclusion criteria were focusing on breastfeeding, eating disorders, obesity treatment, malnutrition, or school-based interventions. Two reviewers independently extracted data and assessed study quality. Twenty-three studies met all criteria. Most were conducted in preschool/childcare (n=9) or home settings (n=8). Approximately half targeted socioeconomically disadvantaged children (n=12) and three quarters were published from 2003 onwards (n=17). The interventions varied widely although most were multi-faceted in their approach. While study design and quality varied, most studies reported that their interventions were feasible and acceptable, although the impact on behaviours that contribute to obesity were not achieved by all. Early childhood obesity prevention interventions represent a rapidly growing research area. Current evidence suggests that behaviours that contribute to obesity can be positively impacted upon in a range of settings and provides important insights into the most effective strategies for promoting healthy weight from early childhood.

Keywords: physical activity, sedentary behaviours, overweight, obesity, children, intervention, eating, pre-school, toddler, early childhood

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Obesity prevention interventions for early childhood: An updated systematic review of the literature

Chapter summary The small number of early childhood obesity prevention studies identified in our previous review of interventions to prevent obesity, promote healthy eating, physical activity, and/or reduce sedentary behaviours in 0–5-year-olds suggests this is a new and developing research area. The current review was conducted to provide an update of the rapidly emerging evidence in this area and to assess the quality of studies reported. Ten electronic databases were searched to identify literature published from January 1995 to August 2008. Inclusion criteria were interventions reporting child anthropometric, diet, physical activity or sedentary behaviour outcomes and focusing on children aged 0–5 years of age. Exclusion criteria were focusing on breastfeeding, eating disorders, obesity treatment, malnutrition, or school-based interventions. Two reviewers independently extracted data and assessed study quality. Twenty-three studies met all criteria. Most were conducted in preschool/childcare (n = 9) or home settings (n = 8). Approximately half targeted socioeconomically disadvantaged children (n = 12) and three quarters were published from 2003 onwards (n = 17). The interventions varied widely although most were multi-faceted in their approach. While study design and quality varied most studies reported their interventions were feasible and acceptable, although the impact on behaviours that contribute to obesity were not achieved by all. Early childhood obesity prevention interventions represent a rapidly growing research area. Current evidence suggests that behaviours that contribute to obesity can be positively impacted upon in a range of settings and provide important insights into the most effective strategies for promoting healthy weight from early childhood.

Introduction Trends in patterns of nutrition, physical activity, and lifestyle factors among pre-school children suggest that early intervention to positively impact weight and behaviours that contribute to obesity is vitally important. In 2006, the authors (Campbell & Hesketh, 2007) conducted a systematic review of the literature to assess the effectiveness of interventions designed to prevent obesity, promote healthy eating, promote physical activity, and/or reduce sedentary behaviours in 0–5-year-olds. The aim was to capture a broad range of research with potential to have positive impact, (p.397) regardless of study design. Nine studies were identified, predominantly published since 2003. The small number and recency of the early childhood obesity prevention literature suggests this is a new and developing research area. A number of reviews of obesity prevention during early childhood have been published in recent years (Bluford et al., 2007; Hearn et al., 2008; Small et al., 2007; Saunders, 2007; Wofford, 2008), all with differing inclusion criteria and predominantly focusing on the preschool age group. The current review was conducted to provide an update of the emerging evidence in this area and to assess the quality of studies reported.

Results The 23 included studies were delivered through a variety of settings: preschool/childcare, home, group, primary care, and mixed settings. Approximately two-thirds involved multi-faceted interventions (n = 14) and a similar proportion were conducted in the USA (n = 15). Just over half of the studies targeted socioeconomically disadvantaged families (n = 12) and three quarters were published from 2003 onwards (n = 17). Design, methodological rigour, and effectiveness varied substantially (see Table 34.1).

Description of key studies Page 2 of 16

Obesity prevention interventions for early childhood: An updated systematic review of the literature

Nine of the 23 studies were described in our previous review paper (Campbell & Hesketh, 2007). Summaries of the remaining 14 studies appear here, grouped by setting. Details of all 23 studies, including a rating of methodological rigour (Thomas, 1998), are provided in Table 34.1. Only three studies received a strong methodological rating, all conducted within the preschool/ childcare setting. Of the remaining 20 studies, 14 were rated as moderate and 6 were rated as methodologically weak. Preschool/childcare-based studies The preschool/childcare setting was the most commonly targeted setting for interventions involving young children. Despite diverse study designs, populations, and targeted outcomes, one-third of these studies achieved clear success in modifying their respective outcomes of interest (reduced fat intake (Williams et al., 2004), increased physical activity (Trost et al., 2008), and reduced sedentary behaviour (Dennison et al., 2002). A further third (Binkley & Specker, 2004; Fitzgibbon et al., 2005; Mo-suwan et al., 1998) showed some evidence of success on some outcomes. Unlike studies reported in other settings, the methodological quality of these studies was generally high (strong or moderate rating). However, inconsistencies within the preschool and childcare setting (e.g. structured versus unstructured, sessional versus long-day), makes generalizability difficult. Two studies (Dennison et al., 2002; Fitzgibbon et al., 2005) conducted in the preschool/childcare setting were described in our previous review (Campbell & Hesketh, 2007), a further seven are described below. Alhassan and colleagues’ (Alhassan et al., 2007) pilot randomized controlled trial (RCT) aimed to increase daily physical activity in 3–5-year-old low-income Latino children in the USA by increasing outdoor free-play time in their structured preschool setting. Intervention group children (n = 18) received double the usual amount of outdoor free-play time (4 × 30-minute sessions) for 2 consecutive days. Children in the control group (n = 15) received their usual 2 × 30-minute sessions. Children in both groups (59% response) wore accelerometers for 4 days, 2 days prior to the intervention and the 2 intervention days. Baseline physical activity levels between groups were similar with all children spending 〉90% of their time being sedentary. No between-group differences were found for changes in average activity counts, percentage of time spent in sedentary, light or (p.398)

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Obesity prevention interventions for early childhood: An updated systematic review of the literature

Table 34.1 Summary of studies: focus, design, sample, quality assessment, and outcome Study

Focusa

Designb

N

Age at Duration Follow-ups commencement

Qualityc Outcomed

Pilot-RCT

32

3–5 yrs

2 days

0

2

0

Cluster-RCT

176

2.5–5.5 yrs

6 mths

6 mths

2

+

Anthro Diet PA SB Preschool/childcare settings Alhassan (USA)

X

Dennisone (USA)

X

Fitzgibbone (USA)

X

X

X

Cluster-RCT

409

3–5 yrs

14 wks

1 & 2 yrs

2

?

Fitzgibbon (USA)

X

X

X

Cluster-RCT

401

3–5 yrs

14 wks

1 & 2 yrs

2

0

Mo-suwan (Thailand)

X

X

Cluster-RCT

292

mean 4.5 yrs

30 wks

0

1

?

Reilly (Scotland)

X

X

Cluster-RCT

545

mean 4.5 yrs

24 wks

6 mths

2

0

Specker & Binkley (USA)

X

X

RCT

239

3–5 yrs

12 mths

6 & 12 mths 2

?

X

RCT

42

3–5 yrs

8 wks

0

1

+

CCT

≈1000 2–5 yrs

2 yrs

0

1

+

Cluster-RCT

50

4–6 yrs

4 wks

0

3

?

CCT

39

birth

1 yr

0

2

+

RCT

43

9 mths–3 yrs

16 wks

0

2

+

RCT

232

birth

1 yr

7 yrs

2

?

RCT

228

4–6 yrs

3 yrs

0

3

+

Trost (USA) Williams (USA)

X

X

Home-based settings Cottrell (USA)

X

Fitzpatrick (Ireland)

X

Harvey-Berinoe (USA & Canada)

X

Johnson (Ireland)

X

Saakslahti (Finland)

X

X

X

Wardlee (England)

X

RCT

143

34–38 mths

14 days

0

2

+

Watt (England)

X

RCT

312

3 mths

9 mths

6 mth

2

0

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Obesity prevention interventions for early childhood: An updated systematic review of the literature

Designb

N

Age at Duration Follow-ups commencement

Qualityc Outcomed

X

Pre/post

60

mean 27 mths

8 mths

0

3

+

Condrasky (USA)

X

CCT

29

preschool

6 x 2hrs 0

3

0

McGarveye (USA)

X

CCT

336

3 yrs

1 yr

1 yr

2

?

Interrupted time series

10,204 n/a

6 mths

6 mths

3

?

RCT

1062

7 mths

10 yrs

0

3

?

Study

Focusa Anthro Diet PA SB

Worobeye (USA) Group-settings

X

Primary care settings Johnsone (USA) Talvia (Finland)

X

X

X

Mixed setting Hordynskie (USA)

X

X

CCT

135

19 mths

6 mths

0

2

?

Johnston (USA)

X

X

CCT

439

Birth (prebirth)

30 mths

0

2

+

a

Anthro = anthropometry; PA = physical activity; SB = sedentary behaviour.

b

RCT = randomized controlled trial; CCT = controlled clinical trial (non-randomized).

c

Quality (methodological rigour as assessed by 6 component rating scale described in methods section (Thomas, 1998)): 1 = strong; 2 = moderate; 3 = weak. d

Outcome: + (intervention was beneficial), 0 (no effect),? (unclear; beneficial for some, but not all, outcomes or participants).

e

Reported in a previous review (Campbell & Hesketh, 2007).

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Obesity prevention interventions for early childhood: An updated systematic review of the literature

(p.399) (p.400) moderate-to-vigorous physical activity for the total day, during school hours or during the after school/evening period. A cluster-RCT (Hip-Hop to Health Jr) aiming to prevent obesity in minority 3–5-year-olds in the USA delivered an identical intervention to two separate cohorts. Results for the first cohort, of predominantly African-American children (Fitzgibbon et al., 2005), indicated lower BMI increases in the intervention group at both 1- and 2-year follow-ups and were reported in our previous review (Campbell & Hesketh, 2007). Results for the second cohort, of predominantly Latino children, are described here (Fitzgibbon et al., 2006). Twelve Head Start preschools servicing predominantly Latino children were randomly allocated to a weight control intervention or general health programme (control group). The weight control intervention (n = 202) involved three 40-minute sessions per week for 14 weeks comprising 20-minute healthy eating or physical activity education and 20-minute aerobic physical activity. Parents received weekly homework and newsletters containing complementary dietary and physical activity information, and were offered twice weekly aerobics classes. The control group (n = 199) received a general health programme involving 20-minute general health education once per week for 14 weeks and parents received a weekly general health newsletter. Although response rate was not reported, post-intervention (14 weeks) retention was 97%, with 86% and 85% completing 1- and 2-year follow-up assessments respectively. At baseline, control group children had higher mean BMI z-scores (p = 0.02) and a greater proportion were Latino (89% versus 73%, p〈0.001). No differences in BMI, dietary, physical activity, or television viewing outcomes were observed between groups at post-intervention, 1- or 2-year follow-ups. Mo-suwan and colleagues (Mo-suwan et al., 1998) aimed to reduce obesity prevalence in preschool children in Thailand by implementing an exercise programme. This cluster-RCT involved second-year kindergarten classes from two preschools. Classes were randomly allocated to the control or intervention condition. Control group children (n = 145) received their regular physical activity programme. Children in the intervention group (n = 147; 75% response) received an additional 15 minutes of walking and 20 minutes of aerobic dance three times per week for approximately 30 weeks. Outcomes were assessed at baseline, twice during the intervention, and at the conclusion of the intervention. The prevalence of obesity assessed from two measures of triceps skinfold thickness decreased in the intervention group (12.2% to 8.8%, p = 0.06) more than in the control group (11.7% to 9.7%, p = 0.18). No between-group differences were found in BMI or weight/height3. However the likelihood of having an increased BMI slope was lower in intervention than control group girls (odds ratio = 0.32, 95% CI = 0.18, 0.56), but not boys. Reilly and colleagues (Reilly et al., 2006) aimed to reduce BMI with the Movement and Activity Glasgow Intervention in Children – MAGIC, by increasing physical activity and reducing sedentary behaviour in this cluster-RCT. A random sample of 36 preschools in Scotland were selected from 104 of a possible 124, stratified by type of preschool (school, class, extended day, private sector), size (area and number of children) and area socioeconomic status. Pairs of preschools from the same stratum were randomly selected and randomly allocated to intervention or control group. Two staff from each intervention preschool attended three training sessions on the enhanced physical activity programme consisting of three 30-minute physical activity sessions per week for 24 weeks. In addition, intervention group families were

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Obesity prevention interventions for early childhood: An updated systematic review of the literature

given information on linking physical play at preschool and home and opportunities for increasing physical activity and reducing television viewing time. Posters on increasing physical activity through walking and play were displayed in preschool centres for 6 weeks. Baseline data were provided from 545 children (47% response). No between-group differences in BMI were observed at 6 months (prior to end of intervention) or 12 months (5–6 months post-intervention). Similarly no differences were observed for physical activity assessed by accelerometry on a subsample of 285 children at 6-month follow-up (not (p.401) assessed at 12 months). Children in the intervention group showed significant improvement in fundamental movement skills at 6 months (not assessed at 12 months). Multiple papers from the USA (Binkley & Specker, 2004; Specker et al., 2001; Specker & Binkley, 2003) report data from an RCT aiming to improve bone mineral content in 3–5-yearolds. The intervention involved four arms: 1. calcium supplement plus physical activity (n = 43), 2. calcium supplement plus fine motor activity control (n = 45), 3. placebo plus physical activity (n = 45), and 4. placebo plus fine motor activity control (n = 45). Results were reported for the physical activity programme independently; arms 1 and 3 results were compared with arms 2 and 4. The physical activity intervention consisted of 30 minutes of gross motor activity 5 days per week for 12 months involving a 5-minute warm up, 20-minute jumping, hopping and skipping activities, and 5-minutes cool down. Five days per week for 12 months, children in the control group received 30 minutes of fine motor activity (e.g. art and craft) designed to keep them sitting quietly. Of the 239 children providing baseline data (response rate not reported), 74% provided mid-intervention (6 months) and post-intervention (12 months) outcomes; 90% of these completed 6-months and 1-year post-intervention follow-ups (n = 161). Children in the intervention group recorded significantly higher physical activity levels, assessed by accelerometry, than control children mid- and post-intervention. This impact persisted 6 months post-intervention but was not observed 12 months post-intervention (6- and 12-month postintervention data collected on subsample of 60 children). No differences in body weight or percentage body fat, assessed by DXA, were observed at any time point. Numerous papers (D’Agostino et al., 1999; Williams et al., 2002; Williams et al., 2004) report the Healthy Start Project, a 3-year demonstration project implemented in Head Start preschools for socioeconomically disadvantaged children in the USA, with the aim of reducing cardiovascular risk factors in 3–5-year-olds. Healthy Start involved a usual care control condition and two intervention conditions and was implemented for 2 years. One intervention condition involved menu modification designed to reduce the total fat and saturated fat content of meals and snacks served at preschool. The second intervention condition involved the menu modification plus a curriculum component whereby children’s health education focused primarily on nutrition. Allocation to one of the two intervention conditions was random, however control group preschools were those who indicated they were unable to make changes to their food service. Sample size is unclear, with reports of the number of children involved differing between papers, from 296 to 〉1000. There was a significant decrease in saturated fat from 13.5% to 8.0%, and total fat content from 31% to 25% of daily energy of meals served at intervention preschools, with no change observed in control preschools (p〈0.001). Dietary observation found reduction in percentage energy from total fat and saturated fat consumed by children in the intervention preschools. Children in both intervention groups demonstrated a

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Obesity prevention interventions for early childhood: An updated systematic review of the literature

significant decrease in total serum cholesterol compared to control group children (−6.0 versus −0.4 mg/dL) but there was no impact on height to weight ratio. Trost and colleagues (Trost et al., 2008) report a USA-based RCT aiming to increase preschool children’s physical activity at a single childcare centre with four classes of children attending an inclusive half-day preschool programme for 2½ hours on each of 4 days per week. After 2 weeks of baseline assessment, classes were randomized to intervention (20 children) or a usual care control condition (22 children; 88% response). Intervention classes received an 8-week ‘Move and Learn’ programme involving integration of physical activity into all aspects of the curriculum. Teachers and staff in the intervention classroom attended a 3-hour training session and received a video demonstrating ‘Move and Learn’ activities. During each preschool session teachers selected a minimum of two activities lasting ≥10 minutes to conduct. Physical activity was monitored by accelerometers and 15 minutes of direct observation during preschool sessions 2 days a week. (p.402) Physical activity levels, assessed by accelerometer, were similar between groups for the first 6 weeks of the programme. Intervention group children demonstrated significantly higher levels of moderate-to-vigorous intensity physical activity than controls in the final 2 weeks of the programme, and the final 4 weeks when only classroom time was assessed. Higher levels of moderate-to-vigorous intensity physical activity were found in intervention group children compared with control group children for the duration of the programme using direct observation.

Home-based studies The home was another common setting for interventions involving young children. Although each of the home-based interventions identified involved quite different population groups, interventions, and outcomes of interest, most showed some positive impact on some behaviours that contribute to obesity. Three (Harvey-Berino & Rourke, 2003; Wardle et al., 2003; Worobey et al., 2004) home-based studies were described in our previous review paper (Campbell & Hesketh, 2007), a further five are described below. Cottrell and colleagues (Cottrell et al., 2005) aimed to assess the impact of a 4-week physical activity plus dietary information intervention called CARDIAC-Kinder among children from the USA. In a cluster-RCT children were recruited via preschools for this intervention, which was delivered in the home setting. The intervention group received a pedometer for themselves and a parent, plus a log book to record their daily steps. Parents received information about ageappropriate diet and exercise guidelines for preschool children and ideas on how to increase exercise, particularly steps. Intervention children whose BMI was ≥85th percentile (number not reported) were also given information on ways to reduce caloric intake. Children in the control group received a pedometer for themselves (but not their parent) plus a daily steps log book. Control parents received the same information about age-appropriate diet and exercise guidelines but no information on how to increase exercise. Although 437 children (50% response) from rural areas were recruited to receive the intervention, data were available for only 24 intervention and 26 control group children. Higher mean weekly step counts were recorded by intervention children compared with controls; however differences were only significant in the final week of the intervention (9815 versus 7799 steps). Intervention group children consumed significantly fewer sweets per week than those in the control group but differences were not reported for average weekly intake of fruits, vegetables, meat, or bread.

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Obesity prevention interventions for early childhood: An updated systematic review of the literature

Seven-year follow-up data are reported (Johnson et al., 2000) for an RCT involving an intervention focusing on parenting skills for first-time parents in disadvantaged areas in Ireland. The Community Mothers’ Programme (Johnson et al., 1993) was delivered by volunteer ‘community mothers’ identified by local public health nurses. Each volunteer supported 5–15 first-time parents via once monthly visits over their child’s first year of life, focused on health care, nutritional improvement, and child development. Results immediately post-intervention fall outside the scope of this review (published pre-1995) but showed that children in the intervention group (n = 127) were significantly more likely to consume appropriately from all food groups than were controls (n = 105). In this study diet was assessed by 24-hour recall with intakes categorized as inappropriate when the subject reported eating not enough or too much from a food group when compared to dietary guidelines. The 7-year post-intervention follow-up assessed one-third of the original group (38 intervention and 38 control mothers) when children were 8 years old. No significant differences in overall child diets were observed between groups. However, children in the intervention group performed consistently better, from 11% to 63% better, than control group children for individual food groups. Although not significant, intervention group mothers were 12% more likely to limit children’s television viewing to no later than 9 pm (p = 0.09). (p.403) Fitzpatrick and colleagues (Fitzpatrick et al., 1997) aimed to assess the Community Mothers’ Programme (described earlier) (Johnson et al., 1993), in a socially marginalized and disadvantaged travelling community in Ireland. Outcomes for these mothers and children were compared to those of intervention and control families in the original RCT informing this work (Johnson et al., 1993) as recruitment of a concurrent control group was considered unachievable. In comparison to mothers involved in the RCT, these disadvantaged mothers (n = 39; response rate not reported) were significantly older and less educated than RCT control but not RCT intervention mothers. Their children were significantly older than children of mothers involved in the RCT, and were not always first-born. Mothers in this study received significantly fewer home visits than did mothers involved in the RCT (mean 8.9 versus 9.5 visits respectively). Children in this study scored better than RCT controls for energy intake and for consumption of all food groups, except fruit. They were also less likely to begin cow’s milk before 26 weeks of age. Sääkslahi and colleagues (Sääkslahti et al., 2004) aimed to influence 4-6 year old children’s physical activity through a 3-year family-based intervention in Finland. Families involved in a larger study were randomly selected to participate in this RCT (response rate not reported). The control group (n = 112) received no information, whereas intervention group parents (n = 116) attended three annual intensive educational meetings with researchers. Meetings dealt with the importance of sensory integration (thought to occur through children’s involvement in physical activity), relations between physical activity, cognitive development, and academic achievement, and how and where to find physical activities and venues that children might enjoy. Parents were also provided with printed education materials twice yearly and relevant review articles. In the second year of the intervention, parents were asked to listen to a radio programme entitled ‘The importance of being physically active’. Intervention group children attended three annual physical activity demonstration sessions lasting 45–60 minutes. Attrition was 26% of intervention and 24% of control families. Children’s physical activity was assessed using diaries

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Obesity prevention interventions for early childhood: An updated systematic review of the literature

completed by the parents twice yearly over the 3 years. The intervention group spent less time playing indoors (p = 0.05) and more time playing outdoors (p = 0.04) than the control group. Time spent outdoors increased in both groups over the 3 years, but more strongly in the intervention group. Further, intervention but not control group children spent more time in ‘high activity play’ (e.g. running, jumping, and other physical exercise) as they grew older (p〈0.001). The Infant Feeding Peer Support Trial (Watt et al., 2006), an RCT, aimed to improve infant feeding practices to a consecutive birth cohort by providing peer support to low-income mothers in England. Control group mothers received usual care (n = 155) and intervention group mothers (n = 157; 82% response) received monthly home visits from matched peer support volunteers, commencing when their baby was 3-months old until their baby was 12 months of age. Volunteers provided non-judgemental advice and support and practical assistance on infant feeding practices, particularly weaning. Outcomes were assessed at baseline, post-intervention (77% retention), and 6-month follow-up (68% retention). At post-intervention and follow-up, no differences between groups were observed in child anthropometric measurements or nutrient intake. Children in the intervention group were more likely to be eating the same foods as the rest of the family and to be eating three meals per day than the control group post-intervention, when 12 months of age.

Group-based studies Two group-based studies were identified from the USA, one (McGarvey et al., 2004) was described in our previous review (Campbell & Hesketh, 2007) and the other is described below. These studies were quite different in setting and focus, but both demonstrated some level of effectiveness. (p.404) Although not utilizing existing social groups per se, both tapped into groups in existing settings; thus participants within groups are likely to have been similar to one another and potentially familiar with one another. These studies demonstrate the potential positive benefits of group-based programmes. Condrasky and colleagues’ (Condrasky et al., 2006) sought to promote healthful eating behaviours by teaching parents and caregivers in the USA basic nutrition, food selection, menu planning, and food preparation skills in a non-randomized controlled trial. The programme, Cooking with a Chef, teamed a chef with a nutrition educator. Lessons were conducted in 2-hour sessions during the week in late morning blocks and concluded with serving lunch. Although not explicitly reported, it appears there were six sessions covering menu planning, using fruits and vegetables, culinary skills, use of flavours, food labels, and dietary fibre. The intervention group (n = 15) comprised a random sample of parents and caregivers of preschool children from a church group. The control group (n = 14; response rate not reported) were randomly selected from a different church group. Pre-post intervention comparisons showed the number of daily fruit servings consumed by children in the intervention group increased after the intervention, although this did not reach statistical significance (p〈0.10).

Primary care-based studies Two studies delivered in the primary care setting in Finland (Lagstrom et al., 1997; Talvia et al., 2004) and the USA (Johnson et al., 2005) were described in our previous review (Campbell & Hesketh, 2007). Additional results for the Finnish study have recently been published and are

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Obesity prevention interventions for early childhood: An updated systematic review of the literature

described below. Both the Finnish and US studies showed some evidence of positive impact on the outcomes of interest. Despite both being rated as methodologically weak, these results suggest primary care may be a useful setting to initiate interventions during the early childhood period. Recently published (Talvia et al., 2006) fruit and vegetable intake outcomes from an RCT that recruited families via well-baby clinics in Finland and was reported in our previous review (Campbell & Hesketh, 2007) are described here. Intervention families (n = 540) received individualized and repeated parental dietary counselling focused on the reduction of the child’s saturated fat intake with the ultimate aim of reducing coronary heart disease risk factors. Counselling sessions occurred at 1–3-month intervals from when the child was aged 7 months until 2 years of age and then biannually to 10 years. Once children were aged 7 years, separate dietary counselling sessions were organized for the child and the parents. Control group parents (n = 522) were seen biannually until the child was aged 7 years and annually thereafter with limited discussion of diet and no counselling on fat intake. The proportion of energy provided by fruits and vegetables reduced over the 10 years of assessment, although total grams of vegetables increased throughout childhood. Intervention boys, but not girls, consumed significantly more vegetables than controls (mean difference 3.2 g/day; CI 1.5–4.9; p〈0.001). Intervention boys also consumed significantly more fruit than controls (mean difference 10.1 g/ day; CI 5.3–14.9; p〈0.001).

Mixed setting studies Studies in which the intervention was delivered across more than one setting were classified as mixed setting studies. Two such studies were identified from the USA, one (Horodynski & Stommel, 2005) was described in our previous review (Campbell & Hesketh, 2007) and the other is described below. Both studies involved non-randomized controlled trials, were rated as being of moderate methodological quality, and focused on improving diet and reducing television viewing. Both showed some evidence of success. (p.405) Johnston and colleagues in the USA (Johnston et al., 2006) compared usual care (control) from birth with a clinic programme known as Healthy Steps for Young Children, implemented with and without an additional antenatal programme known as PrePare. The Healthy Steps programme consists of risk reduction activities and universal components, including developmental screening, anticipatory guidance, and follow-up services delivered by a Healthy Steps specialist. Services were delivered via home visits, parent-initiated telephone support, and parenting classes. The PrePare programme was designed to enable the Healthy Steps specialist to also work with the parent during pregnancy. PrePare was delivered as three home visits at 20, 27, and 34 weeks gestation and focused on helping parents create a safe, knowing, and welcoming environment for their baby and on providing screening and intervention for targeted risk factors such as smoking, depression, and domestic violence. A consecutive sample of 439 pregnant women (80% response rate) was recruited from five primary care clinics. Outcomes were assessed when the child was 30 months old (78% retention). Of importance to this review, parents who received Healthy Steps, when compared to the control group, were significantly less likely to allow their child to watch more than 1 hour of television per day (34% versus 50%). There were no dietary or physical activity benefits of combining PrePare with Healthy Steps.

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Discussion This paper appraised the peer-reviewed literature published between 1995 and mid-2008 that reported interventions, which aimed to support parents and other caregivers to positively influence young children’s body weight and/or the obesity-promoting behaviours of dietary intake, physical activity, and sedentary behaviours. This review aimed to update and extend a previous review conducted by these authors in 2006 (Campbell & Hesketh, 2007). It is clear that obesity prevention interventions focusing on children between the ages of birth and 5 years are gaining increasing attention from researchers, as evidenced by the rapid increase in publications in recent years. Further, it is likely that additional programmes targeting young children have or are currently being conducted but have not yet been published in the peer reviewed literature. In fact the authors are aware of several studies currently being conducted with this age group (Campbell et al., 2008; Wen et al., 2007; Daniels et al., 2009). However, the evidence base remains relatively sparse, particularly when compared to interventions that focus on school-aged children. Given that obesity and behaviours that contribute to obesity have been shown to be prevalent during early childhood and to track across childhood, the importance of early intervention cannot be understated. The studies reviewed here provide a mixed picture of the ability of intervention programmes to change behaviours that contribute to obesity in young children. However, importantly they support the premise that parents and caregivers, even those most at risk of rearing children who will become overweight or obese, are receptive to intervention programmes and in some cases can be supported to make positive changes to dietary, physical activity, and sedentary behaviours of their young children. Further, workers engaged with socioeconomically disadvantaged groups who are at higher risk for obesity, and those providing childcare and early education services, are willing to implement obesity-prevention programmes. Although the evidence base is growing, there remains an urgent need to build in a substantial and integrated way upon this existing evidence base.

Acknowledgements This review was commissioned and funded by the Centre for Health Promotion (South Australia). KH is funded jointly by National Heart Foundation of Australia and the National Health & Medical Research Council. KC is funded by the Victorian Health Promotion Foundation. References Bibliography references: Alhassan, S., Sirard, J., & Robinson, T. (2007) The effects of increasing outdoor play time on physical activity in Latino preschool children. International Journal of Pediatric Obesity 2, 153– 158. Binkley, T. & Specker, B. (2004) Increased periosteal circumference remains present 12 months after an exercise intervention in preschool children. Bone 35, 1383–1388. Bluford, D.A., Sherry, B., & Scanlon, K.S. (2007) Interventions to prevent or treat obesity in preschool children: a review of evaluated programs. Obesity (Silver Spring, MD.) 15, 1356–1372.

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Campbell, K. & Hesketh, K. (2007) Strategies which aim to positively impact on weight, physical activity, diet and sedentary behaviours in children from zero to five years. a systematic review of the literature. Obesity Reviews 8, 327–338. Campbell, K., Hesketh, K., Crawford, D., Salmon, J., Ball, K., & Mccallum, Z. (2008) The infant feeding activity and nutrition trial (infant) an early intervention to prevent childhood obesity: cluster-randomised controlled trial. BMC Public Health 8, 103. Condrasky, M., Graham, K., & Kamp, J. (2006) Cooking with a chef: an innovative program to improve mealtime practices and eating behaviors of caregivers of preschool children. Journal of Nutrition Education and Behavior 38, 324–325. Cottrell, L., Spangler-Murphy, E., Minor, V., Downes, A., Nicholson, P., & Neal, W.A. (2005) A kindergarten cardiovascular risk surveillance study: cardiac-kinder. American Journal of Health Behavior 29, 595–606. D’Agostino, C., D’andrea, T., Lieberman, L., Sprance, L., & Williams, C. (1999) Healthy Start: a new comprehensive preschool health education program. Journal of Health Educaton 30, 9–12. Daniels, L.A., Magarey, A., Battistutta, D., et al. (2009) The nourish randomised control trial: positive feeding practices and food preferences in early childhood - a primary prevention program for childhood obesity. BMC Public Health Oct 14, 387. Fitzgibbon, M., Stolley, M., Schiffer, L., Van Horn, L., Kauferchristoffel, K., & Dyer, A. (2005) Two-year follow-up results for Hip-Hop To Health Jr.: a randomized controlled trial for overweight prevention in preschool minority children. Journal of Pediatrics 146, 618–625. Fitzgibbon, M.L., Stolley, M.R., Schiffer, L., Van Horn, L., Kauferchristoffel, K., & Dyer, A. (2006) Hip-Hop To Health Jr. for Latino preschool children. Obesity (Silver Spring) 14, 1616– 1625. Fitzpatrick, P., Molloy, B., & Johnson, Z. (1997) Community mothers' programme: extension to the travelling community in Ireland. Journal of Epidemiology and Community Health 51, 299– 303. Harvey-Berino, J. & Rourke, J. (2003) Obesity prevention in preschool Native-American children: a pilot study using home visiting. Obesity Research 11, 606–611. Hearn, L.A., Miller, M.R., & Campbell-Pope, R. (2008) Review of evidence to guide primary health care policy and practice to prevent childhood obesity. Medical Journal of Australia 188, S87–S91. Horodynski, M. & Stommel, M. (2005) Nutrition education aimed at toddlers: an intervention study. Pediatric Nursing 31, 364. Johnson, Z., Howell, F., & Molloy, B. (1993) Community mothers' programme: randomised controlled trial of non-professional intervention in parenting. BMJ 306, 1449–1452.

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Johnson, Z., Molloy, B., Scallan, E., et al. (2000) Community mothers programme – seven year follow-up of a randomized controlled trial of non-professional intervention in parenting. Journal of Public Health and Medicine 22, 337–342. Johnson, D., Birkett, D., Evens, C., & Pickering, S. (2005) Statewide intervention to reduce television viewing in Wic clients and staff. American Journal of Health Promotion: AJHP 19, 418– 421. Johnston, B.D., Huebner, C.E., Anderson, M.L., Tyll, L.T., & Thompson, R.S. (2006) Healthy steps in an integrated delivery system: child and parent outcomes at 30 months. Archives of Pediatric and Adolescent Medicine 160, 793–800. Lagstrom, H., Jokinen, E., Seppanen, R., et al. (1997) Nutrient intakes by young children in a prospective randomized trial of a low-saturated fat, low-cholesterol diet. The Strip Baby project. Special turku coronary risk factor intervention project for babies. Archives of Pediatric and Adolescent Medicine 151, 181–188. McGarvey, E., Keller, A., Forrester, M., Williams, E., Seward, D., & Suttle, D. (2004) Feasibility and benefits of a parent-focused preschool child obesity intervention. American Journal of Public Health 94, 1490–1495. Mo-suwan, L., Pongprapai, S., Junjana, C., & Puetpaiboon, A. (1998) Effects of a controlled trial of a school-based exercise program on the obesity indexes of preschool children. American Journal of Clinical Nutrition 68, 1006–1011. Reilly, J.J., Kelly, L., Montgomery, C., et al. (2006) Physical activity to prevent obesity in young children: cluster randomised controlled trial. BMJ 333, 1041. Sääkslahti, A., Numminen, P., Salo, P., Tuominen, J., Helenius, H., & Valimaki, I. (2004) Effects of a three-year intervention on children's physical activity from age 4 to 7. Pediatric Exercise Science 16, 167–180. Saunders, K.L. (2007) Preventing obesity in pre-school children: a literature review. Journal of Public Health (Oxf) 29, 368–375. Small, L., Anderson, D., & Melnyk, B.M. (2007) Prevention and early treatment of overweight and obesity in young children: a critical review and appraisal of the evidence. Pediatric Nursing 33, 149. Specker, B. & Binkley, T. (2003) Randomized trial of physical activity and calcium supplementation on bone mineral content in 3- to 5-year-old children. Journal of Bone and Mineral Research 18, 885–892. Specker, B.L., Johannsen, N., Binkley, T., & Finn, K. (2001) Total body bone mineral content and tibial cortical bone measures in preschool children. Journal of Bone and Mineral Research 16, 2298–2305.

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Talvia, S., Lagstrom, H., Rasanen, M., et al. (2004) A randomized intervention since infancy to reduce intake of saturated fat: calorie (energy) and nutrient intakes up to the age of 10 years in the special turku coronary risk factor intervention project. Archives of Pediatric and Adolescent Medicine 158, 41–47. Talvia, S., Rasanen, L., Lagstrom, H., et al. (2006) Longitudinal trends in consumption of vegetables and fruit in Finnish children in an atherosclerosis prevention study (Strip). European Journal of Clinical Nutrition 60, 172–180. Trost, S., Fees, B., & Dzewaltowski, D. (2008) Feasibility and efficacy of a 'move and learn' physical activity curriculum in preschool children. Journal of Physical Activity & Health 5, 88– 103. Wardle, J., Cooke, L., Gibson, E., Sapochnik, M., Sheiham, A., & Lawson, M. (2003) Increasing children's acceptance of vegetables; a randomized trial of parent-led exposure. Appetite 40, 155–162. Watt, R., Dowler, E., Hardy, R., et al. (2006) Promoting recommended infant feeding practices in a low-income sample – radomised controlled trial of a peer support intervention. Wen, L.M., Baur, L.A., Rissel, C., Wardle, K., Alperstein, G., & Simpson, J.M. (2007) Early intervention of multiple home visits to prevent childhood obesity in a disadvantaged population: a home-based randomised controlled trial (healthy beginnings trial). BMC Public Health 7, 76. Williams, C.L., Bollella, M.C., Strobino, B.A., et al. (2002) ‘Healthy-Start’: outcome of an intervention to promote a heart healthy diet in preschool children. Journal of the American College of Nutrition 21, 62–71. Williams, C.L., Strobino, B.A., Bollella, M., & Brotanek, J. (2004) Cardiovascular risk reduction in preschool children: the 'healthy start' project. Journal of the American College of Nutrition 23, 117–123. Wofford, L.G. (2008) Systematic review of childhood obesity prevention. Journal of Pediatric Nursing 23, 5–19. Worobey, J., Pisuk, J., & Decker, K. (2004) Diet and behavior in at-risk children: evaluation of an early intervention program. Public Health Nursing 21, 122–127. Notes: (*) This chapter has previously been published as Hesketh KD, Campbell KJ. (2010) Interventions to prevent obesity in 0–5 year olds: an updated systematic review of the literature, Obesity (Silver Spring) 18: Suppl 1: S27–35, and is reproduced here with the permission of Nature Publishing Group.

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University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

Problems and possible solutions for interventions among children and adolescents Tom Baranowski Janice Baranowski Karen Cullen Melanie Hingle Sheryl Hughes Russell Jago Tracey Ledoux Jason Mendoza Tuan T. Nguyen Teresia O’Connor Deborah Thompson Kathleen Watson

DOI:10.1093/acprof:oso/9780199572915.003.0035

Abstract and Keywords This chapter provides an overview of childhood obesity causes and discusses the efficacy of potential preventive interventions. Interventions for obesity prevention generally have had no or limited effects with no obvious patterns in findings to guide program development. The chapter assumes imbalances in dietary intake and physical activity account for most of the problem. To elucidate the problems in obesity prevention research, the Mediating Moderating Variable Model (MMVM) is used to deconstruct the variables and pathways from intervention design to change in adiposity, and thereby elucidate problems at each step in intervention design, implementation, and evaluation. As more is learned about these causal pathways, intervention protocols may be developed that offer different or different intensity interventions to subgroups that may need different procedures.

Keywords: Mediating Moderating Variable Model, MMVM, overweight, obesity, children, intervention, health promotion, physical activity, USA, model

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Chapter summary This chapter provides an overview of childhood obesity causes and a discussion about the efficacy of potential preventive interventions. Interventions for obesity prevention generally have had no or limited effects with no obvious patterns in findings to guide programme development. This chapter assumes imbalances in dietary intake and physical activity account for most of the problem. To elucidate the problems in obesity prevention research, the Mediating Moderating Variable Model (MMVM) is used to deconstruct the variables and pathways from intervention design to change in adiposity, and thereby elucidate problems at each step in intervention design, implementation, and evaluation. As more is learned about these causal pathways, intervention protocols may be developed that offer different or different intensity interventions to subgroups who may need different procedures.

Conceptual framework for organizing analysis High levels of obesity may be due to a variety of causes (McAllister et al., 2009) and this chapter assumes imbalances in dietary intake and physical activity account for most of the problem. To elucidate the problems in obesity prevention research, the Mediating Moderating Variable Model (MMVM) is used to deconstruct the variables and pathways from intervention design to change in adiposity, and thereby elucidate problems at each step in intervention design, implementation, and evaluation (Baranowski et al., 2010). An MMVM reveals an intervention must be designed and implemented; the implemented intervention should induce change in one or more mediating variables (psychological, social, or environmental); changes in the mediating variables should induce change in the behaviours (aspects of diet or physical activity); and changes in the behaviours should induce change in the indicator of adiposity or obesity (Baranowski et al., 2010). This model has nodes (i.e. conceptualization/intervention design, intervention implementation, mediating (p.409) variables, behaviours, adiposity) and sequential relationships between the nodes. This chapter will start with the adiposity node and work backwards to conceptualization/intervention design.

Adiposity/obesity node It is possible that little progress has been made in preventing obesity because our measures of adiposity are inadequate, thereby inhibiting the ability to detect true relationships (Bar-Or & Baranowski, 1994). We have accepted low standards for quality in our measures, with the excuse that good measures cost too much to develop or implement. However, not detecting true effects, thereby providing misleading results, is not cost effective. Although BMI has been the most commonly used indicator of adiposity, it does not (1) distinguish between fat mass and fat free mass, (2) inform about fat distribution (e.g., visceral versus subcutaneous; truncal versus other fat), (3) always positively correlate with adiposity, or (4) take into account age, gender, or ethnic differences in the association between BMI, body fat, and disease outcomes (Daniels, 2009; Freedman & Sherry, 2009; Stevens, 2008). Differences in reference populations across countries and in methods to identify cut-points lead to differences in cut points (Butte et al., 2006; Himes, 2009). Epidemiological studies in representative samples from countries with diverse BMI distributions showed inconsistencies in the prevalence of overweight and obesity when different classification systems were used (Mei et al., 2008; Tuan & Nicklas, 2009; Wang & Wang, 2002). Since each BMI classification system has its strengths and limitations, no universal set of BMI cut-points have been accepted

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internationally (Butte et al., 2006; Neovius et al., 2004). A universal set of cut-points cannot accommodate differences in associations among BMI, body fatness, and cardiovascular disease risk factors in children and adolescents across racial/ethnic groups (Freedman et al., 2009; Johnson et al., 2009; Katzmarzyk et al., 2004; Messiah et al., 2008). For example, at a given lower BMI level, Asians may have higher percentage body fat and cardiovascular disease risk compared to other racial and ethnic groups (Freedman & Sherry, 2009). Although BMI z-score might be a more precise measure for monitoring a patient in clinical and intervention studies, it is not widely used because its results are harder to explain to patients (Daniels, 2009). A preferred method would be to generate and use sample specific regression equations using combinations of anthropometric and demographic variables to predict a precise measure of body fat, e.g. DEXA, in a representative sample before the main study (Lohman et al., 2000), and using that combined predicted variable as the best indicator.

Behaviour/environment to obesity relationships Although each case of obesity is a result of caloric intake exceeding caloric expenditure, the reasons for that excess vary (e.g. lack of satiety from meals, little or no enjoyment from physical activity). The needed level of caloric deficit to remedy obesity also likely varies by individual. For example, in a study with twins, there were huge between-pair differences in response to a constant caloric excess (Bouchard et al., 1990), or caloric deficit (Bouchard, 2008). The caloric intake deficit to remedy obesity has been estimated to be as little as 100 kcal/day (Hill & Peters, 1998) to as much as several thousand calories/day (Bouchard, 2008; Wang et al., 2006). At least 25 genes were consistently related to adiposity in five or more studies (Rankinen et al., 2006), suggesting many biological mechanisms. Although several earlier studies suggested a strong relationship, the genetically induced taste sensitivity to a bitter compound (6-n-propylthiourical) found in cruciferous vegetables accounted for only 1% of the variability in adiposity and only among the upper socioeconomic status group (Baranowski et al., in press). Diet has received much attention for causes of the epidemic, but causal, highly predictive dietary targets for change have been difficult to identify. One intervention project that achieved change in BMI targeted increasing dietary fibre intake, but no effects were detected in dietary fibre (p.410) (Fitzgibbon et al., 2005). No consistent evidence was found that higher sugar sweetened beverage consumption (a high caloric, low nutrient, density food) was related to adiposity (Bachman et al., 2006). Increased fruit and vegetable (FV) intake has been proposed as an obesity prevention strategy (de Oliveira et al., 2008; He et al., 2004; Vioque et al., 2008; WHO, 2002) because FV intake may displace energy-dense foods (Fisher et al., 2007; Rolls et al., 2004); enhance satiation from its fibre content (Howarth et al., 2001; Ludwig et al., 1999); or moderate dietary glycemic load, affecting postprandial hormonal shifts (Ebbeling et al., 2003; Livesey et al., 2008). However, a review of experimental and longitudinal studies testing the association of FV consumption to adiposity among adults and children showed that higher levels of FV intake were only weakly associated with weight loss or slower weight gain primarily among overweight or obese adults, and only when they were part of an overall emphasis on energy intake reduction; and among children the results were inconclusive (Ledoux et al., Submitted). Perhaps obesity prevention interventions should target portion size, as in the research on ‘mindless eating’ (Vartanian et al., 2008), or satiety mechanisms (i.e. anything can

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make us fat if we eat too much of it) (Popovic & Duntas, 2005). Perhaps children compensate for intervention changes in other environments.

Behaviour node: need for better measures Although positive energy balance (i.e. excess caloric intake) is a plausible biological cause of weight gain and increased body fatness (Hervey, 1969), research has failed to detect this association (Gray & Smith 2003; Savage et al., 2008) or confusingly suggested the inverse (Fiore et al., 2006). Part of the problem is inadequate measurement. Assessment of children’s diet by 24-hour recall or food frequency questionnaire is prone to reporting bias (Livingstone et al., 2004), which has led to under- or overestimation of energy intake (EI) by as much as 54% (Huang et al., 2004; Livingstone et al., 2004), by as many as 50% of children and adolescents (Huang et al., 2004) leading to distorted representations of total EI (Huang et al., 2005), macronutrient composition (Lafay et al., 1997), and eating patterns (Huang et al., 2005), and inaccurate conclusions about relationships among diet and adiposity (Rosell et al., 2003). The obese tend to under report intake (Livingstone & Black, 2003). By assuming EI and energy expenditure (EE) are balanced, implausible dietary data can be identified (Livingstone et al., 2004) and then eliminated (Fiorito et al., 2006; Huang et al., 2005; Ledoux et al., Under Review; Ventura et al., 2006), but this has been done infrequently. Physical activity has been associated with lower body mass among children (Jago et al., 2005), but school physical education has not (Harris et al., 2009). Self-report methods provide reasonable estimates of the types of activities in which children engage, but generally have not been related to adiposity (Bar-Or & Baranowski, 1994). Accelerometers measure vertical acceleration (Janz, 1994) and have been correlated with directly measured energy expenditure (Puyau et al., 2004; Treuth et al., 2003).

Mediating variables to behaviour linkage Home availability of fruit and vegetables could be an important mediator of children’s fruit and vegetable consumption. Qualitative studies indicated perceived home fruit and vegetable availability was associated with intake among 4th—6th grade children (Baranowski et al., 1993; Cullen et al., 2000a). Cross-sectional quantitative research indicated home fruit and vegetable availability was associated with self-reported intake among girls, but not boys (Cullen et al., 2003; Hanson et al., 2005). An intervention that focused on developing skills asking for fruit and vegetables at home resulted in a 0.8 serving increase in fruit and vegetable intake (Baranowski et al., 2002b). These findings suggest that increasing home availability of fruit and vegetables will yield increases in children’s consumption, but no studies have directly increased home availability and assessed consumption. (p.411) Knowledge and self-efficacy were strong predictors of intake in high availability homes, but not low availability homes. Thus, home fruit and vegetable availability moderated the associations between self-efficacy, knowledge, and fruit and vegetable intake (Kratt et al., 2000).

Mediating variable node: need for better measurement Seven categories of mediating variables have been proposed as identifying the most common categories of influences on behaviour, which should guide future research (Baranowski et al., 2010). Social cognitive theory (Bandura, 1986, 1997) has been used extensively to understand

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youth physical activity. Self-efficacy, which can be interpreted as a person’s perceived selfcompetence to engage in an activity, is a central component of social cognitive theory (Bandura, 1997) and numerous studies have reported positive correlations between physical activity selfefficacy (PASE) and physical activity among youth (De Bourdeaudhuij et al., 2005; Jago et al., 2006; Trost et al., 1999). Despite these associations, few studies have reported that PASE functioned as a mediator of physical activity change among either youth (Dishman et al., 2004) or adults (McAuley et al., 2003; Prodaniuk et al., 2004). The absence of a mediating effect may be caused by an inability of the intervention to change self-efficacy, a failure of the assessment methods to accurately capture change in self-efficacy, or the lack of a relationship that is large enough to change behaviour.

Intervention delivery to mediating variable linkage The major procedure for attempting to induce behaviour change has been enhancing participant knowledge. This reflects a dominant implied theory of ‘enlightened self interest’, suggesting that people will do what is in their best self interest, and all we have to do is inform them of what that is. Unfortunately, knowledge based interventions do not change behaviour (Contento et al., 1995) and models of rationality do not predict behaviour (Shafir & LeBoeuf, 2002). Sometimes the intervention may not be appropriate for a targeted audience. One intervention with preschoolers was based on modelling from social learning theory, choice from self determination theory and cognitive stages of change from the Trans-Theoretical model (Fitzgibbon et al., 2005). It is not clear, however, that choice or cognitive stages of change describe meaningful processes among preschoolers. The authors reported a parent component in their pilot study, apparently emphasizing modelling, but they experienced low participation. Thus, programmes that resulted in slower growth in BMI in some children provided little insight into what psychosocial or other variables mediated the pathways to change. There is little empirical documentation that specific intervention procedures result in change in targeted mediating variables, no less some titration of change in mediation in response to variation of intensity and amount of procedures. In fact, only half of the mediators selected by interventionists showed any change, and those showing change were weak (Baranowski et al., 1997; Baranowski et al., 1998). Although many interventions targeting parents distributed newsletters, there is no evidence that newsletters reach parents or induce change (Baranowski & Jago, 2005; O'Connor et al., 2009).

Intervention delivery node: need for innovative models and measurement of process A model has been proposed that relates the process of programme delivery to outcomes, linking dose and fidelity of programme delivery to reach, reception, changes in mediators, and behaviour (p.412) (Baranowski & Jago, 2005). Measures of these delivery constructs are needed to better understand quantitatively how programmes effect change (Resnicow et al., 1998). A recent innovative pilot obesity prevention intervention in pediatric primary care emphasized training pediatricians and dietitians in motivational interviewing (Schwartz et al., 2007). The high drop out rate in the intensive intervention group, however, pointed out a delivery problem using primary care for an intervention that required multiple contacts, and the self selective continued attendance may account for the positive findings in that only families perceiving a benefit likely came back.

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Video games are a popular form of entertainment among both adults and youth. When designed within a framework informed by behavioural science and supported by commercial game design principles, serious video games have the potential to be an effective method for achieving longterm change in health behaviours by targeting key mediating variables. Squire’s Quest! II is a 10-episode action adventure video game told from the first person perspective that has a goal to increase fruit and vegetable consumption. It focuses on increasing practical knowledge, skill, competence, and intrinsically focused motivation (Thompson et al., in preparation) through game play features such as character dialogue, casual games that test knowledge and provide immediate feedback, character modelling, ‘virtual’ recipe preparation, and setting goals in the game world that have to be achieved in the real world. Similar procedures have been used in other video games designed to influence the health behaviour of youth (Thompson et al., 2008) and deserve more intensive development and evaluation.

Conceptualization node: need for new theories The paucity of effective behaviour change interventions argues for finding innovative theories of behaviour to guide intervention development. Self Determination Theory (SDT) is such a multicomponent theory (Ryan & Deci, 2000), that posits behaviour is extrinsically or intrinsically motivated. SDT posits that behaviour is driven by three basic psychological needs: competence (i.e., behaviour-specific knowledge, skills); autonomy (i.e., personal choice, control); and relatedness (i.e., connection to important others or personal values). Strategies to enhance basic psychological needs can be incorporated into behaviour change interventions (Niemiec & Ryan, 2009). For example, emphasizing choice and self-control enhances autonomy. Providing optimal challenges (i.e., not too easy or hard), equipping individuals with appropriate tools (i.e., knowledge, skills) and providing effectance feedback enhances competence. Feeling the behaviour or goal is endorsed or supported by important others promotes relatedness. Connecting values to reasons for engaging in a particular behaviour may enhance relatedness (Thompson et al., 2007; Thompson et al., 2008). Designing interventions to enhance need satisfaction likely increases internalization and integration of the behaviour, thereby increasing motivation to perform the behaviour and maintenance of the behaviour (Rothman, 2000). Parenting has been implicated in the causal pathway to child obesity (Ventura & Birch, 2008). Parenting style has been linked to child weight status (Rhee et al., 2006) and nutrition behaviours (Kremers et al., 2003; van der Horst et al., 2007). Most studies on parenting practices have investigated restrictive, the most controlling, feeding practices (Birch et al., 2001; Faith et al., 2004; Hughes et al., 2008; Ogden et al., 2006; Ventura & Birch, 2008; Wardle et al., 2005). A recent conceptual framework identifies the dimensions of responsiveness, demandingness/control and structure (Hughes et al., 2008) to facilitate the evaluation of effective and ineffective parenting practices to promote healthy child eating behaviours. Research on parenting influences on children’s physical activity (Davison et al., 2003; Jago et al., 2009a) and TV viewing behaviours (Barradas et al., 2007; Davison et al., 2005) also is emerging. Expanding a food parenting conceptual model to also include PA and TV parenting practices would allow future evaluations of parental influences on (p.413) several obesity-related behaviours that may be inter-related casual pathways. Successful prevention of child obesity targeting parenting style and parenting practices (Barradas et al., 2007; Darling & Steinberg, 1993; Davison et al., 2003) may need to be implemented under a sequential-mediation model

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(SMM). An intervention based on SMM would target parental mediating variables (e.g. psychosocial, ecological) of effective parenting practices (behaviours), which influence change in children’s mediating variables, then child behaviours and child adiposity. It is not clear that a model with so many probabilistic links will influence child behaviour.

Innovative context dependent interventions Effective interventions must be informed about the contexts or environments in which they are implemented, and target strategically important (causal and strong) influences on behaviour. Schools likely influence child adiposity. In the US, the National School Lunch and School Breakfast Programmes (NSLP and SBP) are available in 99% and 85% of public schools (2004, 2007b). In 2007, about 60% of children ate a NSLP lunch and about 24% ate a school breakfast (2007b). School meals must meet programme regulations based on national dietary guidelines for calories, fat, saturated fat, fruit and vegetables, grains, protein foods, milk, and certain nutrients (2007a; Ralston et al., 2008). Foods may also be available in snack bars, a la carte lines, vending machines, and school stores (Ralston et al., 2008). There were no government guidelines for these competitive foods, except for foods of minimal nutritional value like soda (Ralston et al., 2008). Significant relationships among school food environments, children’s practices, and body mass index (BMI) have been found in cross-sectional data. Middle school students with access to snack bar/a la carte foods consumed more sweetened beverages and French fries, and fewer fruit and vegetables compared with elementary school students without snack bars (Cullen & Zakeri, 2004; Cullen et al., 2000b). About 40% of students consumed one or more competitive foods on a typical school day, which were energy-dense and low in nutrients (Fox et al., 2009b). Offering French fries and desserts in NSLP meals more than once a week were each associated with a significantly higher likelihood of obesity in elementary school children (Fox et al., 2009a). Access to vending machines with energy dense foods was associated with a higher BMI z score for middle school students, although having such foods available for purchase in the cafeteria a la carte line was associated with a lower BMI z score (Fox et al., 2009a). Participation in the NSLP was not significantly related to students’ BMI and school breakfast participants had significantly lower BMI than did nonparticipants (Gleason et al., 2009). Three studies assessed changes in body weight after cafeteria improvements. A middle school intervention that marketed low-fat foods reduced body mass index for intervention condition boys (Sallis et al., 2003); an elementary school intervention improved school level BMI percentiles compared with control condition schools (Coleman et al., 2005); however, both studies were confounded by improvements in physical education classes. A policy-based intervention in grades 4–6, including nutrition education, parental outreach, and guidelines on foods allowed in school food environments (including the elimination of all sweetened beverages) obtained a significant reduction in the incidence of overweight for students (Foster et al., 2008). No details, however, were provided on dietary intake, food sales, or the PE programme. Changes in the school food environment improved middle school student lunch dietary intake (Cullen et al., 2008; Schwartz et al., 2009). Texas School Nutrition Policy, which restricted portion sizes of snacks/beverages, overall fat content, and serving of high fat vegetables like

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French fries, resulted in desirable decreases in dietary energy among middle school students (Mendoza et al., 2010a). When soft drink machines were unavailable during lunch, high school students purchased fewer soft drinks compared to students in schools where vending machines were on during lunch (p.414) (Neumark-Sztainer et al., 2005). A high school environmental intervention promoting availability of lower-fat foods resulted in a greater rate of increase in lower-fat food sales in the first year of the intervention, and in year 2 (Foster et al., 2008). After implementation of nutrition standards for competitive foods in high schools, the proportion of purchases of low nutrient dense foods declined, whereas purchases of mid- and high-nutrient dense foods increased (Snelling & Kennard, 2009). None of these studies, however, investigated whether children compensated with more unhealthy food choices outside of school. Parental perception that their child’s overweight status is a health problem has been associated with parental readiness to make changes to affect their child’s weight status (Rhee et al., 2005). Six studies evaluated obesity treatment interventions in primary care settings (McCallum et al., 2007; Patrick et al., 2006; Saelens et al., 2002b; Schwartz et al., 2007; Wake et al., 2009; Young et al., 2004). Two resulted in improved weight status (Saelens et al., 2002a; Young et al., 2004) and four in some improvement in obesity-related behaviours (dietary, sedentary, or physical activity) (McCallum et al., 2007; Patrick et al., 2006; Schwartz et al., 2007; Young et al., 2004). Although primary care may be a promising setting in which to deliver obesity interventions (Thomas, 2006), few studies (if any) reported mediators that were targeted to achieve parental behaviour change or specified how parents were involved to help support behaviour change in their children. Active commuting to school (ACS), i.e. walking or cycling to and from school, has been associated with higher levels of physical activity (Davison et al., 2008; Lee et al., 2008). Walking School Bus (WSB) programmes, first reported in Australia (Engwicht, 1993), are a group of children led to and from school by adults who walk along a set route with predetermined neighbourhood ‘bus stops’, where children join the group. Quasi-experimental trials have shown that WSB programmes were associated with greater rates of ACS (Mendoza et al., 2009; Staunton et al., 2003) and physical activity (Heelan et al., 2009). Among a nationally representative sample, before- and after-school MVPA mediated the relationship between ACS and lower waist circumference, with borderline mediation with the other measures of adiposity (Mendoza et al., 2010b).

Conclusions The lack of significant effects from many existing obesity prevention programmes, and the confusion at every node and relationship in the mediating variable model, suggest the need to rethink approaches to designing and developing obesity prevention interventions (Baranowski et al., 2009). A first step needs to detect and verify the diet and physical activity behaviours that are causally and substantially related to adiposity in a target population (Baranowski et al., 2009). If research cannot identify causally and substantially related influences at this stage, why take a chance that a large expensive intervention study attempting to influence these causal pathways, will obtain meaningful behavioural and anthropometric change. Once meaningful influences are detected, innovative procedures need to be tested for changing the influencing variables to an extent great enough that meaningful changes will occur in the behaviours and

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subsequently in adiposity. As more is learned about these causal pathways, intervention protocols may be developed that offer different or different intensity interventions to subgroups who need different procedures (called SMART interventions (Collins et al., 2007)). This will keep us busy for quite a while. References Bibliography references: Anonymous. WHO consultation. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. (World Health Organ Tech Rep Ser 2000, 894: i–xii, 1–253). Anonymous (2003a) WHO. The world health report 2002. World Health Organization, Geneva. Anonymous (2003b) WHO/FAO expert consultation. Diet, nutrition and the prevention of chronic diseases. WHO, Report No. 916, Geneva. Anonymous (2004) Effects of food assistance and nutrition programs on nutrition and health, Vol. 4. Executive summary of the literature review. Food Assistance and Nutrition Research Report Number 19-4. USDA/ERS (U.S. Department of Agriculture/Economic Research Service). USDA/ERS (U.S. Department of Agriculture/Economic Research Service, Washington, DC. Anonymous (2007a) School Nutrition Dietary Assessment Study-II.USDA/FNS, Alexandria, VA. Anonymous (2007b) USDA/FNS, School Nutrition Dietary Assessment Study-III. Alexandria, VA. Bachman, C.M., Baranowski, T., & Nicklas, T.A. (2006) Is there an association between sweetened beverages and adiposity? Nutrition Reviews 64(4), 153–174. Bandura, A. (1986) Social foundations of thought and action: a social cognitive theory, Prentice Hall, Englewood Cliffs, NJ. Bandura, A. (1997) Self-efficacy: the exercise of control, Freeman, New York. Bar-Or, O. & Baranowski, T. (1994a) Physical activity, adiposity and obesity among adolescents. Pediatric Exercise Science 6, 348–360. Baranowski, T. & Jago, R. (2005) Understanding mechanisms of change in children's physical activity programs. Exercise and Sport Sciences Reviews 33(4), 163–168. Baranowski, T., Anderson, C., & Carmack, C. (1998) Mediating variable framework in physical activity interventions. How are we doing? How might we do better? American Journal of Preventive Medicine 15(4), 266–297. Baranowski, T., O'Connor, T., & Baranowski, J. (2010) Initiating change in children's eating behavior. In V.R. Preedy, R.R. Watson, & C.R. Martin (Ed.) International handbook of behavior, diet and nutrition. NY: Springer.

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Thomas, H. (2006) Obesity prevention programs for children and youth: why are their results so modest? Health Education Research 21(6), 783–795. Thompson, D., Baranowski, T., Buday, R., et al. (2007) In pursuit of change: youth response to intensive goal setting embedded in a serious videogame. Journal of Diabetes Science and Technology 1(6), 907–917. Thompson, D., et al. (2008) Serious video games for health: how behavioral science guided the development of a serious video game. Simulation & Gaming, doi:10.1177/1046878108328087 (ahead of print). Treuth, M., et al. (2003) Defining accelerometer thresholds for physical activity intensities in adolescent girls. Obesity Research 11(Suppl.), A33. Trost, S.G., Plate, R.R., Ward, D.S., Saunders, R., & Riner, W. (1999) Correlates of objectively measured physical activity in preadolescent youth. American Journal of Preventive Medicine 17(2), 120–126. Tuan, N.T. & Nicklas, T.A. (2009) Age, sex and ethnic differences in the prevalence of underweight and overweight, defined by using the CDC and IOTF cut points in Asian children. European Journal of Clinical Nutrition 63(11), 1305–1312. van der Horst, K., Kremers, S., Ferreira, I., Singh, A., Oenema, A., & Brug, J. (2007) Perceived parenting style and practices and the consumption of sugar-sweetened beverages by adolescents. Health Education Research 22(2), 295–304. Vartanian, L.R., Herman, C.P., & Wansink, B. (2008) Are we aware of the external factors that influence our food intake? Health Psychology 27(5), 533–538. Ventura, A.K. & Birch, L.L. (2008) Does parenting affect children's eating and weight status? International Journal of Behavioral Nutrition and Physical Activity 5, 15. Ventura, A.K., Loken, E., Mitchell, D.C., Smiciklas-Wright, H., & Birch, L.L. (2006) Understanding reporting bias in the dietary recall data of 11-year-old girls. Obesity (Silver Spring) 14(6), 1073–1084. Vioque, J., Weinbrenner, T., Castelló, A., Asensio, L., & Garcia de la Hera, M. (2008) Intake of fruits and vegetables in relation to 10-year weight gain among Spanish adults. Obesity (Silver Spring) 16(3), 664–670. Wake, M., Baur, L.A., Gerner, B., et al. (2009) Outcomes and costs of primary care surveillance and intervention for overweight or obese children: the LEAP 2 randomised controlled trial. BMJ 339, b3308. Wang, Y. & Wang, J.Q. (2002) A comparison of international references for the assessment of child and adolescent overweight and obesity in different populations. European Journal of Clinical Nutrition 56(10), 973–982.

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Wang, Y.C., Gortmaker, S.L., Sobol, A.M., & Kuntz, K.M. (2006) Estimating the energy gap among US children: a counterfactual approach. Pediatrics 118(6), e1721–e1733. Wardle, J., Carnell, S., & Cooke, L. (2005) Parental control over feeding and children's fruit and vegetable intake: how are they related? Journal of the American Dietetics Association 105(2), 227–232. WHO (2002) Diet, nutrition and the prevention of chronic diseases. Report of the joint WHO/FAO expert consultation. WHO Technical Report Series, No. 916 (TRS 916). Young, P.C., West, S.A., Ortiz, K., & Carlson, J. (2004) A pilot study to determine the feasibility of the low glycemic index diet as a treatment for overweight children in primary care practice. Ambulatory Pediatrics 4(1), 28–33. Notes: (*) This chapter has been prepared by one of the authors as part of their official duties as U.S. government employees and is not covered by copyright.

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University Press Scholarship Online Childhood Obesity Prevention: International Research, Controversies and Interventions Jennifer A. O'Dea and Michael Eriksen

Print publication date: 2010 Print ISBN-13: 9780199572915 Published to University Press Scholarship Online: January 2011 DOI: 10.1093/acprof:oso/9780199572915.001.0001

(p.423) Index 1Seven – Move More, Eat Well 295 5-A-Day Power Plus 339, 340, 341 1990 British growth charts 5 2000 CDC growth charts  5, 84–5 ABC study  353, 356 Aboriginal Australians  97, 98, 99, 100, 101 Aboriginal childhood obesity in Canada  309–20 access to unhealthy foods  216–17 Achieving Cultural Change  231 Action Schools! BC – Healthy Eating  327 Active After Schools Programme  284 Active-Ate  293 Active Australia  282 Active Australia Schools Network  283 Active Balance Childhood (ABC) study  353, 356 adiposity and BMI  4, 409 adolescents body dissatisfaction  269–70 functions and benefits of nutrition  31 obesity and family income in Canada  42–55 obesity and its prevention in Asian adolescents in New Zealand  250–7 obesity prevention in African Americans  333–47 paid employment  44, 48, 52, 53–4 perceptions of benefits of healthy eating  32, 33 school-based obesity prevention programme  269, 271–5 trends in obesity in Brazil  144–51 adult obesity, link to childhood obesity  195, 196 advertising  170, 214–15, 334

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advocacy  236, 264 African American children and adolescents, obesity interventions  333–47 African American Collaborative Obesity Research Network (AACORN)  352 alcohol control  221–2 America SCORES Bay Area project  336 ANGELO  352 Annapolis Valley Health Promoting Schools Program  22 anti-dieting approach  273–5 APPLE  326 Arkansas legislature  219 Asian populations, cut-off values  101 at risk for overweight  8, 85 attitudes  188 Australia food policy  231–2, 234 perceptions of benefits of healthy eating  32, 33 school-based prevention  278–99 trends in childhood obesity  69, 71, 72, 73, 74, 76, 95–103, 157 Austria, trends in childhood obesity  71, 72 availability of unhealthy foods  216–17 Bahrain, prevalence of childhood obesity  175 ballet students  374 Be Active (2004–2008)  292 Be Active Queensland  289 Be Active WA  293 beauty, concept  275 Be Fab  275 Be Fit  272–3 Be Fueled  273–5 behavioural consequences of weight-related teasing  365, 370–3 behavioural intentions  206 behavioural treatment  196–7 behaviour change models and theories  205–8 Belgium, trends in childhood obesity  71, 72 beliefs  188 belonging  44–5, 48, 52, 53, 54 binge eating  274 Birmingham Healthy Eating and Active Lifestyle for Children Study (BEACHeS)  355 blame  36–7, 57 bland diets  230 blood pressure  9; see also hypertension BMI report card  17, 19, 23 body dissatisfaction  269–70, 365

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body fat distribution trends  73 body image  275, 335 body mass index (BMI) adiposity indicator  4, 409 BMI report card  17, 19, 23 children  4 cut-off values  6, 10, 11 distribution in US  86 health risks and outcomes  9 high BMI-for-age  4, 6 historical aspects  3–4 historical trends  70 labelling problems  8, 23–4 reference data sets  4–6 screening tool  10, 20–3 surveillance  10, 17 body size, cultural perception  158–9 Bogor, trends in childhood obesity  136 Brazil, trends in adolescent obesity  144–51 breastfeeding  190, 260 British 1990 growth charts  5 built environment  75 bullying  20 (p.424) caloric intake and weight loss  409 Canada Aboriginal childhood obesity  309–20 adolescent obesity and family income  42–55 school-based screening and monitoring  20–3 surveillance  20–2 trends in childhood obesity  71, 72 Canadian Community Health Survey  21 CAN PLAY  21 Canteens Accreditation Programme  286 CARDIAC-Kinder  401 cardiovascular risk  9, 152, 189 CATCH (Child and Adolescent Trial for Cardiovascular Health)  22, 326, 339–40, 341, 353, 355 CATCH-ON  339 CDC 2000 growth charts  5, 84–5 central fat  73 childcare-based interventions  337–8, 397, 398, 399 childhood obesity and overweight, terminology  7–8 Chile, trends childhood obesity  71, 72, 144 China, trends childhood obesity  73, 74, 76, 104–16, 129, 175

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China Health and Nutrition Survey (CHNS)  106, 109–12 China National Nutrition (and Health) Surveys (CNNHS)  104, 105–6, 108–9, 111–12 China National Surveys on Students’ Constitution and Health (CNSSCH)  104, 105, 107–8, 111– 12 CHIPS  323 Cochrane Collaboration  235 Cole (IOTF) reference  6 collaborative approaches  222, 280 collective action  222–3 ‘Colourful and bright fruits and vegetables project’  125, 127–8 communication  235 community environment  216 health providers’ role  259, 264 interventions  327–8 physical activity involvement  255 school–community partnerships  280 Community Mothers Programme  401–2 comparison trap  275 comprehensive interventions  336, 339 Comprehensive Multidisciplinary Intervention  199 computer use  140, 382, 411 consolidation of knowledge  234–5 consumer information processing  205–6 Cooking with a Chef  404 Croatia, trends in childhood obesity  71, 72 Crunch’n’sip  283 cultural issues body size  158–9 interventions  304, 351–8 social determinant of health  312–13 cut-off values  6, 10, 11 Czech Republic, trends in childhood obesity  71, 72 daily energy expenditure  44 daycare settings  337–8 DEAL study  357 Denmark, trends in childhood obesity  71, 72 depression  196, 365 diabetes  9, 101, 196 diet changing trends  169–70 Chinese children  112 expert committee recommendations  259–60

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Hong Kong children  118, 119, 124–5, 126 parental control  138, 264 Singapore children and adolescents  241–2 Diet and Active Living (DEAL) study  357 diet cycle  274 dieticians/dietetics students  59, 60 discrimination  35 Down syndrome  189 drug-related obesity  189 drug treatment of obesity  37, 197 Dutch Obesity Intervention in Teenagers  209 eating behaviour fussy eating  230 healthy to disordered spectrum  270 intuitive  273–4 eating disorders  59, 60, 245, 374 Eating Disorders Awareness and Prevention (EDAP) puppet programme  374 Eating Smart, Eating for Me  374 Eat it!  295 Eat Smart Play Smart  294 Eat Well Australia  281 Eat Well Be Active SA (2006–2010)  296 Eat Well Do Well  389, 390–94 ecological factors  280, 297 ecological model  204–5, 207–8, 258–64 Aboriginal childhood obesity in Canada  311–14 interventions  313–15 economic factors  25, 217–18; see also socioeconomic status EDAP puppet programme  374 education diet and exercise  246 health promotion  255 level of education and prevalence of obesity  149, 187 level of parental education  43, 50, 52, 93, 118, 120, 121, 122, 123, 124, 125, 139 peer educator schemes  383–4 Egypt, prevalence of childhood obesity  156, 157 empowerment  252 Energizers  324, 338 environment assessment  26, 27 built  75 community  216 food  322–4

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home  125, 127, 139–40 hypertension link  158 information  213–16 interventions  321–32, 337–40 schools  26, 127–8, 217, 280, 297 (p.425) social  221–2 systemic  26 Estudo Nacional de Despesa Familiar  145 ethnicity  43, 80, 86, 87–8, 97, 98, 99, 100, 101–2, 189, 348–51 European Heart Health Initiative (2001)  383 evidence-based practice  223–4 exercising behaviour, healthy to disordered spectrum  270 family income  42–55, 125 structure  241 weight-related teasing  364 Finland, trends in childhood obesity  71, 72 FitKid  336, 337 5-A-Day Power Plus  339, 340, 341 foetal origins of adult disease hypothesis  251 food, social norms  223 food choices  37–8 food deserts  25 food environment  322–4 food industry  27, 223 food labelling  215–16 food neophobia  230 food policy knowledge management  230–5 strategies  236–7 food pricing  323 food security  25, 44, 52, 313 Framework for Action on Healthy Body Weight in Children  314 France, trends childhood obesity  71, 72, 73, 74, 76 Fresh Tastes NSW Healthy School Canteen Strategy  285 FriarFit  339 fruit and vegetable consumption Chinese children  112 ‘Colourful and bright fruits and vegetables project’  125, 127–8 expert committee recommendations  260 family income  44, 51–2 free fruit and vegetable programme  322

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home availability  409–10 Hong Kong children  119, 124, 125 media campaigns  221 National School Fruit and Vegetable Scheme  390 pricing  323 Singapore children  241 fussy eating  230 gastric banding and bypass  190, 198 GEMS  336, 337, 352, 356 gender differences in obesity  107, 108, 111–12, 134–5, 137, 147, 148–9, 157–8, 165, 167, 169 in physical activity participation  45, 138, 380–1 genetic factors  158, 195, 409 Germany, trends in childhood obesity  71, 72 Get Moving Tasmania  291 Girl Pages workbook  272 Girls’ Health Enrichment Multi-Site Studies (GEMS)  336, 337, 352, 356 Global Strategy on Diet, Physical Activity and Health (WHO)  383 global trends in childhood overweight and obesity  69–83; see also individual countries goal-setting  304 Go For Your Life  294 Go For Your Life Healthy Canteen Policy  286 GoNT Be Active  292 government regulation  27, 219–20 Greenland, trends in childhood obesity  73, 74, 76 group-based interventions  305, 399, 403–4 growth charts  5, 84–5 Hannaford system  215–16 headaches  189 Head Start  338 health behaviour influences  203–4 multiple determinants and multiple levels  204–5 Health Behaviour in School-Aged Children Study  21 health care costs  222 health determinants  312–13 health education, potential harm  32, 34–7 health insurance  222 health literacy  279 health outcomes, BMI values  9 health professionals  258–66 Health Promoting Schools  278–99 health promotion

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Asian adolescents in New Zealand  253–6 bottom-up  252 general framework  252–3 top-down  252 Health Promotion Board (HPB)  242–3 health risks BMI values  9 of obesity in childhood  189, 196, 229 health screening avoidance  36 health service avoidance  36 Healthy Active Australia  281 Healthy Canteen Guidelines  287 healthy eating non-dieting approach  273–5 perceived benefits  32, 33 Healthy Eating Active Communities  339 Healthy Eating Guidelines  287 healthy food choices  37–8 Healthy Living Cambridge Kids  327–8 Healthy Schools – Healthy Kids (HSHK)  375 Healthy Schools Initiative  288, 383 Healthy Start Project  401 Healthy Steps for Young Children  405 heaviness  7 Heavy Weight 2008 283–4 high BMI-for-age  4, 6 Hip Hop to Health  353, 354, 400 home-based interventions  398, 402–3 home environment  125, 127, 139–40 homework  113, 140 Hong Kong, trends in childhood obesity  71, 72, 117–28 (p.426) hospital-based interventions  301–2 hunger and fullness scale  274 hypertension  152, 153, 154–5, 156, 157, 158 ICAPS  325–6 immigrants  43 India, prevalence of childhood obesity  175 individually-targeted interventions  305, 335–7, 341 individual responsibility  222–3 Indonesia, trends in childhood obesity  136, 138 Infant Feeding Peer Support Trial  403 information  255 information environment  213–16

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Instant Recess™  338, 339 institutional factors  259, 264 intellectual disability  189 International Obesity Task Force (IOTF) cut-off values  6 internet-based interventions  302 interpersonal factors  259, 264 intervention mapping  209 interventions childcare-based  337–8, 397, 398, 399 community-based  327–8 comprehensive  336, 339 culturally-appropriate  304, 351–8 ecological model  313–15 environmental  321–32, 337–40 food environment  322–4 gender-specific  341 group settings  305, 399, 403–4 home-based  398, 402–3 hospital-based  301–2 individual  305, 335–7, 341 internet-based  302 length and effectiveness  303 mixed settings  399, 404–5 multi-component  324–8 multidisciplinary  190 neighbourhood-based  327–8 nutrition-based  25, 325, 326–7, 336, 337, 338–9, 341 parental involvement  190, 300–8 physical activity  197, 324, 325–7, 336, 337, 338, 382–6 policy  321–32 preschool-based  397, 398, 399 primary care  399, 404, 414 school-based  25–6, 220–1, 243–6, 314–15, 323–7, 337, 338, 353, 355, 382–6, 389–95, 413–14 Singapore experience  243–6 systematic review  396–407 intrapersonal factors  258, 259–64 intuitive eating  273–4 Iran, trends in childhood obesity  175, 182–4 iron deficiency anaemia  189 Israel, trends in childhood obesity  187–92 Italy, trends in childhood obesity  71, 72, 73, 74, 76 Jakata, trends in childhood obesity  136 Japan, trends in childhood obesity  71, 72

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JUMP-in  325 Kahnawake Schools Diabetes Prevention Project  314–15, 353, 355 Keil Obesity Prevention Study  22 knowledge management  230–5 Kuwait, prevalence of childhood obesity  156, 175 labelling, BMI measures  8, 23–4 labelling food  215–16 language  8 LEAP  325, 338, 340 Lebanon, prevalence of childhood obesity  156 legislation  218–19 lifestyle Singapore  241 small modifications  301 Lifestyle Education for Activity Program (LEAP)  325, 338, 340 lipid levels  9, 189 Lithuania, trends in childhood obesity  71, 72 litigation  220 lone-parents  43, 50 lunchtime supervisors  393 Macao, trends in childhood obesity  117, 128 macroenvironment  322 MAGIC  400–401 Malaysia, trends in childhood obesity  136, 137, 138 Maori  97, 98, 99, 101 marginalization  37 marketing  170, 214–15 maternal overweight and obesity  139, 300 media  170, 221, 275 media literacy  297 Mediating Moderating Variable Model (MMVM)  408–9 medicalization  37 medication-related obesity  189 Meridia®  197 Mexico, trends childhood obesity  144, 157 microenvironment  321–2 micronutrient deficiency  229–30 Middle Eastern countries, trends in childhood obesity  174–86; see also individual countries Middle School Physical Activity and Nutrition Study (M-SPAN)  326 military service  246–7 milk consumption  119, 125 misinformation  35 Model School Tuckshop programme  246

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monitoring, food policy  231–2 Morocco, prevalence of childhood overweight  156 motivational interviewing  272 Move and Learn programme  401 Movement and Activity Glasgow Intervention in Children (MAGIC)  400–401 Move Well Eat Well  291–2 M-SPAN  326 multi-component interventions  324–8 multidisciplinary intervention  190 multi-factorial approaches  223 (p.427) NAP SACC programme  327 National Center for Health Statistics (NCHS) growth charts  5 National Health and Nutrition Examination Survey (NHANES)  85 National Healthy Lifestyle Program (NHLP)  242 National Longitudinal Survey of Children and Youth  21 National Nutrition and Physical Activity Study  32, 96 National School Fruit and Vegetable Scheme  390 National School Lunch Programme  412 NCHS growth charts  5 neighbourhood interventions  327–8 Netherlands, trends in childhood obesity  71, 72, 73, 74, 77 New Moves  269, 271–5, 384 New Zealand obesity and its prevention in Asian adolescents  250–7 socioeconomic status and obesity risk  101 trends in childhood obesity  73, 74, 77 non-alcoholic fatty liver disease  189 non-dieting approach  273–5 nutrient deficiency  229–30 NutriSTEP  21, 22–3 nutrition education  37–8 functions and benefits  31 interventions  25, 325, 326–7, 336, 337, 338–9, 341 policy strategies  236–7 Nutrition Transition  158 Obesity Prevention in Communities (OPIC) Project  357 1Seven – Move More, Eat Well  295 opportunity  216–17 orlistat  197 Out of School Hours Care  285, 289–90 Pacific Islanders  97, 98, 99, 100 parents

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control of children’s diet  138, 264 education level  43, 50, 52, 93, 118, 120, 121, 122, 123, 124, 125, 139 involvement in intervention  190, 300–8 overweight and obese  139, 300 parenting skills training  304 parenting style  196–7, 412–13 partnerships  236–7, 280 PASS & CATCH  338, 339 Pathways study  353, 354 peers infant feeding peer support  403 peer educators  383–4 weight-related teasing by  363–4 PEN-3  352 PEOPLE System  253 Pesquisa de Orçamentos Familiares  145 Pesquisa Nacional Saúde e Nutrição  145 Philippines, trends in childhood obesity  136, 138 physical activity Chinese children  112–13 community role  255 family wealth  43–4, 45, 381 gender bias  45, 138, 380–1 Hong Kong children  118, 119, 122, 123, 126 interventions  197, 324, 325–7, 336, 337, 338, 382–6 New Moves programme  272–3 obesity prevention programmes  36 participation levels  380–2 promotion  158, 221 self-efficacy  411 Singapore school children  242 social norms  223 trends in participation  75, 170 physical education teachers  58, 59, 60 Planet Health  22, 338, 339, 341 playgrounds  324 Poland, trends in childhood obesity  71, 72 policy development, knowledge management  230–5 policy interventions  321–32 Polynesians  101, 102 popularity  44 possible risk of overweight  8 poverty  19

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poverty income ratio (PIR)  90, 92–3 Prader-Willi syndrome  189 prejudice  35 PrePare programme  405 preschool interventions  397, 398, 399 Preventing Childhood Obesity: Health in the Balance  209 prevention of obesity adverse effects  32, 34–7 African American children and adolescents  333–47 physical activity promotion  158 school-based  269, 271–5, 278–99 Singapore experience  240–9 teachers’ role  35 training  35 Prevention Plus  199 primary care interventions  399, 404, 414 Program Champions  325 Project EAT  269–70 psychological problems  196, 365, 366–9 psychotropic medicine  189 public health policy  27 public policy  259, 264–5 quality of life  189, 196 race  86, 87–8 Ready-to Go  285 reference data sets  4–6 refugees  97, 102 regulations  27, 219–20 research and food policy  232, 234 review of knowledge  234–5 rural areas, see urban versus rural areas Russia, trends in childhood obesity  71, 72, 73, 175 (p.428) Sandy Lake School Diabetes Prevention Program  315 Saudi Arabia, prevalence of childhood obesity  175 schizophrenia medication  189 school activity breaks during academic classes  324, 338 ‘Colourful and bright fruits and vegetables project’  127–8 community partnerships and services  280 dining rooms  391–2 environment  26, 127–8, 217, 280, 297 ethos  280 food offerings and prices  323, 337, 338–9

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food policy  231–2 gardens  323–4 homework  113, 140 intervention role  25–6, 220–1, 243–6, 314–15, 323–7, 337, 338, 353, 355, 382–6, 389–95, 413–14 location  138 long hours at school  242 lunchtime supervisors  393 meals  389–95 National School Fruit and Vegetable Scheme  390 organization  280 playgrounds and equipment  324 prevention role  269, 271–5, 278–99 screening  17, 19–23 surveillance role  17 treatment of obesity  57–8 vending machines  26 weight bias  58–9 weight-related teasing reduction  373–6 School Breakfast Programme  413 School Health Action Planning and Evaluation System (SHAPES)  21, 22 School Nutrition Policy Initiative (SNPI)  339, 340 Schools Assistance Act (2005–2008)  282 School Sport Policy  289, 290–1 screening BMI  10, 20–3 Canada  20–3 post-screening action  24–5 potential harm  24 school-based  17, 19–23 systems level  26–7 sectoral change  235 self determination theory  411 self-efficacy  207, 410 self-esteem  275, 365 self-reports  22 sequential-mediation model (SMM)  413 service intervention  394 SHAPES  21, 22 Shape-Up Sommerville  327 sibutramine  197 ‘sick role’  37 Singapore

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obesity prevention and management  240–9 trends in childhood obesity  136 single parents  43, 50 skinfold thickness, historical trends  70, 72–3 sleep  75 Smart Choices  284 Smart Moves  288 snack foods  236, 323 social cognitive theory  207, 271 social determinants of health  312–13 social ecological model  207–8, 258–64, 311–14 social environment  221–2 social exclusion  44–5 social isolation  196 social marginalization  37 social norms  223 socioeconomic status (SES)  26, 37, 80, 86, 89–90, 92–3, 96, 97, 98, 99, 100–1, 135, 137, 138, 167, 381 soft drink consumption  140 South Africa, trends in childhood obesity and hypertension  152–63 Southeast Asia, trends in childhood obesity  132–43 soya milk consumption  119, 125 Spain, prevalence of childhood obesity  71, 72 spatial imagination  391–2 Sportsperson in Schools Programme  291 Sri Lanka, prevalence of childhood obesity  175 staged treatment  198–200, 261–4 stages of change  206–7 Star Choice Canteen Accreditation Programme  288 Stephanie Alexander Kitchen Garden Project  294 stereotyping  18, 35 stigmatization  8, 17, 18–20, 35, 58, 196, 208, 244 Structured Weight Management  199 Students and Parents Actively Involved in Being Fit  336 stunting  174–5 suicidal thoughts  365 surgical treatment  190, 197–8 surveillance BMI  10, 17 Canada  20–2 food policy  231–2 schools  17 Sweden, trends in childhood obesity  71, 72, 73, 74, 78, 164–73

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Switzerland, prevalence of childhood obesity  71, 72, 73, 74, 78 systematic review, interventions  396–407 systemic environment  26 systems level screening  26–7 TAAG  325, 338 Taiwan, trends in childhood obesity  117, 128–9 Take 10! Program  324, 338, 340 tax policy  217–18 teachers knowledge of weight, nutrition and obesity  56–7 personal eating and exercise behaviour  59–61 (p.429) stigmatizing obesity  19 training  57, 59, 61–2 transference potential  35 weight bias  58–9 teasing, see weight-related teasing TEENS study  325 television viewing  75, 140, 197, 214, 334–5, 382 temperament  196–7 terminology issues  7–8 Tertiary Care Intervention  199 Thailand, trends in childhood obesity  136, 139 theory  204 theory of planned behaviour  206 thinness  164–5, 168 tobacco control  209, 214, 216, 217–18, 220, 222 traffic light system  215 training  35, 57, 59, 61–2 trans fat bans  27 transference  35 treatment of obesity approaches  196–8 behaviour-based  196–7 drugs  37, 197 risks  198 school role  57–8 staged approach  198–200, 261–4 surgery  190, 197–8 Trial of Activity in Adolescent Girls (TAAG)  325, 338 ‘Trim and Fit’ programme  243–6 type 2 diabetes  9, 101, 196 underweight, trends in prevalence  164, 168

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United Arab Emirates, prevalence of childhood obesity  175 United Kingdom, trends in childhood obesity  71, 72, 73, 74, 79 United States of America obesity prevention in African Americans  333–47 trends in childhood obesity  71, 72, 73, 74, 79, 84–94 unsupervised weight control  32 urban versus rural areas  107, 109, 111–12, 153, 154, 156, 182 vending machines  26 VERB  221, 338, 340, 341 Very Important Kids (V.I.K.)  375–6 victim blaming  36–7, 57 victimization  20 Victorian Institute of Sport Sportsperson in Schools Programme  291 video games  412 Vietnam, trends in childhood obesity  134–5, 137, 138, 139, 140 vitamin B12 deficiency  189 Walking School Bus  414 warning labels  215 weight bias in schools  58–9 weight control inappropriate and unsupervised  32 unhealthy behaviours  270 weight-related teasing  20, 58 consequences  363, 365–73 definition of teasing  363 by family members  364 by peers  363–4 school-based reduction initiatives  373–6 Whole Schools Approach  278–99 World Health Organization (WHO) Global Strategy on Diet, Physical Activity and Health  383 growth charts  5 Health Behaviour in School-Aged Children Study  21 Health Promoting Schools Framework  278–99 Xenical®  197 Youth Cultures of Eating Study  96 Youth Risk Behaviour Surveillance System (YRBSS)  118

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