W1005: An Integrated Approach to Prevention of Obesity in High Risk Families
Statement of Issues and Justification
Overweight and obesity have reached epidemic proportions in the United States. The proportion of adults who are overweight increased substantially between 1980 and 2002 (CDC, 2005). By 2002, 65% of U.S. adults (20-74 yrs of age) were overweight and 31% were obese. Likewise, obesity has become the most prevalent nutritional disease of children and adolescents (Dietz, 1998, CDC, 2005). Children from low SES and racial/ethnic minority groups tend to have higher rates of obesity in comparison to other groups (Nesbitt et al., 2004; Thompson et al., 2003). Among adults, obesity rates are about 28% for men regardless of racial/ethnic group membership. Adult women have higher rates of obesity than males. Obesity rates are higher among Hispanic women (39%) than White women (31%) and even higher (50%) among African-American women (CDC, 2005). It is well known that chronic disease risks increase with increasing body weight (Mokdad et al., 2001). It is also clear that overweight and obese children are likely to remain overweight and obese adults and to develop chronic diseases at younger ages (Ebbing et al., 2002).Obesity was first declared a major public concern in 1952 (Nestle and Jacobson, 2000). Since then billions of dollars have been spent to prevent and intervene with no discernable effect. It is obvious that we need new approaches. The complexity and multifaceted nature of obesity development and its intractability strongly argue for multi-disciplinary approaches. Clearly, obesity has genetic roots. However, the argument that genetic predisposition to obesity makes obesity inevitable (Speakman, 2004) is no more productive in terms of prevention/intervention than the traditional "eat less, exercise more" solution (Fairburn and Cooper, 1996; Wardle, 1996, Nestle and Jacobson, 2000). Safe, effective and affordable pharmacologic and genetic interventions are, at best, years away from discovery. Stakeholders, individuals, the scientific community, educators and health care providers, cannot and should not wait for drug or genetic "cures" for obesity. Unfortunately, long-term, multi-million dollar campaigns to change behavioral and environmental risks for obesity development have not been able to document success in slowing the rise in obesity prevalence (Nestle and Jacobson, 2000). While children learn eating behaviors from adults and peers (Jansen et al., 2003), there are relatively few studies examining the role of the family in shaping and supporting behaviors leading to weight gain, loss, or maintenance (IOM, 2000;).
Resilience Resilience is a characteristic that exists only in a condition of adversity. Such is the current situation: families find themselves living within an obesogenic environment. Examples of what they face include exposure to television advertising; large portions; frequent eating away from home experiences; limited physical activity; etc. Since not all low-income children are overweight, it safely can be assumed that some low-income families negotiate through this environment without their children becoming at risk for, or overweight (regardless of genetic influence). What makes these families different (e.g. resilient) from others in the same environment? Only by comparing families can this question be resolved. Once differences are revealed, then realistic interventions can be designed, presented and evaluated.
Targeted Behaviors Much has been written about which factors are associated with the development, treatment and prevention of childhood overweight (Agras & Mascola, 2005, Boon & Clydesdale 2005, Dehghan et al. 2005, Must & Tybor, 2005, Patrick & Nicklas, 2005, Phillippas & Lo, 2005, Sherry, 2005.) Key behaviors identified are listed below. The assumption has been that if these behaviors could be mitigated, the prevalence of childhood overweight would decrease. Therefore, these are topics suggested to be targeted for interventions.
" high intake of sweetened beverages (including fruit juice) " sedentary behaviors vs. regular physical activity " lower intakes of fruit and vegetable " few family meals " frequent eating out " skipping breakfast " large portion sizes " unlimited TV/media viewing " high intake of energy-dense, nutrient poor snack foods " specific parenting behaviors (e.g. restrictive feeding practices; parental control over child's food intake; pressuring child to eat; rewarding with food; parental dietary intake and dieting practices; parental concern of child's weight and family functioning).
In a review of household behaviors, Whitaker (Whitaker 2004) noted the following as the highest ranked behaviors for four behavioral domains. Specifically, these are reducing screen time (physical activity/inactivity domain); limiting portion sizes and eating meals away from home (eating context domain); limiting sugar-sweetened beverages (foods consumed domain); and breastfeeding (parent feeding domain). In another review, restriction was the only feeding domain associated with increased food consumption and weight status of children (Faith, K.S. Scanlon et al. 2004).
The American Dietetic Association commissioned a group of researchers to explore the strength of evidence of the relationship of many of these key targeted behaviors to childhood overweight(http://www.adaevidencelibrary.com/). None of these behaviors were given a Grade of I (considered to be supported by good/strong evidence). At best, a few were deemed to be supported by evidence of fair value (II). Most on the list were supported by limited or weak data (III).
Yet these are the very topics that are promoted as targets for preventing childhood overweight. As such, community nutrition educators and other health professionals may be directing efforts towards these topics by providing classes, designing written materials, making videotapes, planning social marketing campaigns, etc. in an attempt to help low-income families make food and activity choices that will prevent childhood obesity. A paucity of information exists at the community level as to whether or not these topics are being covered; the amount of time, money, and other resources being devoted to these topics; and the extent of the impact of these efforts.
Logic Model One way to try to capture impact of community interventions (as opposed to randomized clinical trials) is to use the Logic Model (McCawley 2001; Medeiros, Butkus et al. 2005). By collecting information in a systematic way, agencies can determine the extent of the impact of their work on a variety of community members over time. The goal of the Community Nutrition Education Model (Medeiros, Butkus et al. 2005) is to provide educational programs and social marketing activities that increase the likelihood of people making healthy food choices consistent with the most recent dietary advice as reflected in the Dietary Guidelines for Americans and the Food Guidance System, with special attention to people with limited budgets. This model can be adapted for the purposes of developing and evaluating interventions to prevent childhood obesity in low income families.
Practice Informs Research Traditionally, health practitioners working within the community setting have relied on researchers to inform their practice (e.g. to help them direct their efforts to improve the health and well-being of members of their community). This approach is the final step in the medical model: results of randomized clinical trials (or other types of research studies) are shared with experts and practitioners who then translate the research outcomes into usable strategies for consumers. The underlying assumption of this approach is that once people know what is good or right, they will change their behaviors. For issues regarding communicable diseases, this procedure has been very effective. This can be seen with the disappearance of many infectious diseases. It also has been effective, over a period of 25 years or so, in relation to the reduced incidence of smoking and increased seat belt use. However, there is increasing evidence that this process may not be as effective when it involves behaviors related to overall health and well-being, e.g. reduction of chronic diseases (Buchanan 2000). That is, it is not simply a matter of translating research information about healthful eating and physical activity choices into oral or written messages. Knowledge does not automatically lead to changes in behavior when it relates to practices that have strong economic and cultural implications. Furthermore, to research the impact of community-level intervention requires different models than clinical trials. Often, randomized controlled studies cannot be done. Furthermore, human behavior is not predictable; therefore, using standardized strategies to collect valid information may be cumbersome or unrealistic.
Perhaps it is time for practice to inform research. In other words, before attempting to take all the new information constantly flowing from research institutions, it might be best to do the type of field research that will identify what changes individuals and families might be able and willing to consider. It also would be informative to see what tools practitioners need BEFORE attempting to initiate an intervention so that the impacts could be measured.
This proposal deviates from the traditional model of research informing practice by first exploring what is currently being done by practitioners with a concurrent exploration into more useable physical screening tools(McDowell, Fryar et al. 2005). These activities are followed by ethnographic studies of families with children between the ages of 4-10 years old to distinguish parental behaviors that override the obesogenic environment. Upon completion of activities and integration of results, a framework for implementing realistic intervention strategies will emerge.
This research requires a transdisciplinary approach. Expertise is required in nutrition, family and child ecology, health behavior change theory, nutrition education, communications, social statistics and qualitative research methodology. The Multistate Research approach is ideal for fostering this type of transdisciplinary work. Bringing researchers with a wide range of expertise together will provide a platform for developing innovative, multidimensional methods for obesity assessment, prevention and intervention in a community based setting. Multistate research will allow for increased resource capacity, including larger sample sizes. This will provide more confidence in the reliability and validity of results and, in turn, a stronger foundation for devising and testing interventions.
Hypothesis: 1 Parent-child relationships underlie key behaviors associated with resilience to childhood overweight. 2 Anthropometric and physiological measures exist that can distinguish between resilient and overweight children in low-income families within the community setting.
1 Key behaviors associated with childhood obesity (and hence targeted for intervention) include high intake of sweetened beverages; sedentary behaviors; lower intakes of fruit and vegetable consumption; few family meals; unlimited TV/media viewing; high intake of energy-dense, nutrient poor foods; and specific parenting behaviors (e.g. restrictive feeding practices; parenting style).
2 Resilience is a characteristic that exists only in a condition of adversity. Such is the situation of the current "obesogenic" environment in which families live (e.g. exposure to television advertising; large portions; frequent eating away from home experiences; limited physical activity; etc.).
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