The four-year-old girl is barely taller than she is wide. Her padded forehead just reaches my waist. She struggles to rise from the floor on bowed legs, as if she were stricken with polio. Her parents ask me, a dietitian at a pediatric obesity research centre, how I can help their daughter.
At 4 years old, she knows only the physical struggle of weighing twice what other kids her age weigh. Within the year, she will go to school and feel stares from children who would rather be sick than be fat. She will encounter discrimination and emotional anguish, leading to coping mechanisms centred in inactivity and comfort foods.
The New England Journal of Medicine reported in 2007 that the current generation’s life span in North America may be up to five years shorter than their parents’. The economic cost of physical inactivity and overeating, measured in direct costs such as hospital visits and physician care, and indirect costs such as production lost due to short- and long-term disability, was estimated in 2005 to be over $5-billion in Canada. Childhood obesity in Canada has increased threefold in as many decades. Since the likelihood of losing weight decreases with increasing age, and this gives complications such as hypertension, heart disease and diabetes more years to develop, our education and healthcare systems are scrambling to change the trajectory.
Some of the answers are rather obvious. The 2004 Canadian Community Health Survey (CCHS) reported that our kids are eating more high-calorie, low-nutrient junk and fast foods than ever before. More than half of Canada’s children do not meet the minimum daily servings of low-calorie, nutrient-rich fruits and vegetables recommended by Canada’s Food Guide. Children spend too much time in front of TV and computer screens, some as much as their parents spend at full-time jobs. Yet, knowing what our children are doing or not doing is only a small part of the puzzle.
Obesity rates are not uniform across the country. The CCHS reported that children in the Maritime provinces have the highest rates: 36 per cent of children in Newfoundland and Labrador and 34 per cent in New Brunswick are overweight or obese. Alberta’s classrooms have significantly fewer overweight and obese children: 22 per cent. It’s not coincidental: research priorities, innovative policy, and cultural realities seem to account for much of the difference. Indeed, while childhood obesity is the subject of intense research across the continent, Albertan health professionals, educators, researchers and parents are leading the search for answers to the rapid growth of our children.
Researchers at the University of Alberta and at Alberta Health Services–Capital Health, are working to determine why obesity occurs, and to change the course of the path our future adults are walking.
Two of these future adults are Amy and Andrew Janewski. A treadmill and an exercise bike sit in the bay window overlooking the Janewski family’s pie-shaped lot in Millwoods. Mary Anne and Tim, parents of Amy and Andrew, nod at the exercise equipment, cumbersome in the small living room. “We’d tried everything,” sighs Mary Anne, remembering the abundance of advice that doctors and other parents dispensed.
Obesity rates are not uniform across Canada; Alberta has significantly fewer overweight and obese children. Research priorities, innovative policy, and cultural realities account for much of the difference.
Amy, 12, and Andrew, 10, are both overweight. Their BMIs have been above the 95th percentile for most of their lives. Their dad, Tim Janewski, is fully aware of his children’s weight status and what it means to people around them. His face reddens in anger as he explains. “Other parents told us we weren’t feeding them right,” he says. “They weren’t being helpful. There was just no support, there were no constructive ideas.”
Amy, sitting cross-legged on a chair in the middle of the room looks at her dad. “The doctor just said, ‘Amy, you need to lose weight,’” she recalls. “How do you do that?”
“I felt guilt and shame,” Mary Anne adds. “I used food and activities as rewards and punishments. Our relationship with food and exercise was warped.”
Both Mary Anne and Tim have backgrounds in teaching. The well-being of children—especially their own—is their priority. Never did this become more important than after visiting the Pediatric Centre for Weight & Health (PCWH). A blood test revealed Andrew had unusually high cholesterol. Where healthy cholesterol is less than 5, Andrew’s was over 9.
It was a frightening reality check most families don’t encounter. Few people have their cholesterol checked before the age of 30, but Andrew was diagnosed with familial hypercholesterolemia, an inherited disorder that causes very high cholesterol levels because the liver cannot adequately remove cholesterol from the blood. He was prescribed a healthy diet and regular physical activity.
When I met Andrew, he looked like every other overweight kid I counselled. The scariest aspect of pediatric obesity however, is that we are just discovering the myriad of medical complications happening inside kids’ bodies. Think of carrying a 50- or 100-pound bag of sand everywhere you go. Your feet would be flattened, your back would ache and your heart would be working overtime. It would be hard to breathe.
A young researcher with a quick smile and firm handshake, Dr. Geoff Ball has studied pediatric obesity treatment programs for over a decade. His enthusiasm for his work is obvious as he leans forward to describe his most recent work at the PCWH. “It’s the first of its kind in Canada,” says Ball of the research-based clinical program in the Stollery Children’s Hospital. The centre is part of Capital Health’s Weight Wise program, an initiative created to provide weight management programs for overweight people in the region.
“The PCWH is primarily a research centre,” he explains. “Research takes time and a large number of people—by nature, it’s expensive. But being focused on research has allowed us time for reflection and evaluation, critical to overweight treatment, of which our knowledge is actually very little.” Ball states this last part emphatically. “Alberta’s lower childhood obesity rates are a combination of all the factors that lead to obesity, and it’s impossible to say exactly why Alberta has fewer overweight kids. But we’re working really hard to keep it that way and to be a leader in the country.”
Ball’s research focuses on the design, delivery and evaluation of family-focused weight management programs for overweight children. Parenting is a skill. As children grow and new obstacles such as weight problems develop, parents need to change how they parent—a difficult task and a delicate issue. But parents are far more in charge of what their children eat than many realize, and Ball’s research is testing a model that supports parents as they become the health advocate the family needs. For teens, the programs emphasize skill building, enhancing self-efficacy (confidence in being able to accomplish something) and building competencies and relationships with peers. Parents remain involved, with education and problem-solving sessions.
“Our programs concentrate on the family because we think that’s how everyone will have the most sustainable success,” explains Ball. The Janewskis took part in a 16-week program covered under Alberta healthcare that included nearly 30 hours with health professionals.
The PCWH has a holistic approach drastically different from the usual, didactic medical model. Traditional medical evaluation and success are usually based on numbers such as weight and cholesterol, but the PCWH programs instead aim to identify why families behave as they do, and then determine how to mediate changes in those behaviours. Behaviours are difficult to measure, and they only indirectly impact measurable numbers like weight and cholesterol. “But that’s reflective of the nature of obesity,” reasons Ball. “It’s a conundrum.”
To begin treating the many factors that affect obesity, the PCWH employs exercise specialists, dietitians, psychologists, endocrinologists and nurses, as well as the research staff that creates, evaluates and disseminates the research. All of this requires considerable resources, which the majority of health regions across the country do not have. Alberta has a definite financial and intellectual advantage. “If we can’t begin solving the obesity epidemic in Alberta, I’m not sure where we can,” says Ball.
Treatment is critical for those suffering from being overweight, but at the end of the day, obesity prevention will have greater overall impact on our children’s health.
To prevent obesity, we must first understand how it happens. Researchers at the University of Alberta are trying to determine how it is that our environment has become obesogenic—meaning an environment that engenders obesity. Dr. Paul Veugelers studies healthy lifestyles and socio-economic factors as they relate to obesity and chronic disease, aiming to inform health policies. Veugelers, who recently moved to Alberta from Nova Scotia to join the emerging Centre for Health Promotion Studies (CHPS) in the School of Public Health at the U of A, speaks passionately of his philosophy. “We need to alter the environment to make healthy choices the easy ones,” he says. “People are accustomed to certain types of choices, and we can hopefully change that.”
Essentially, Veugelers believes we can lead a kid to the vending machine but we don’t make him think. “Give him the choice between milk and water, not pop and water,” he explains. Veugelers suspects that by preventing poor choices, we can tip the balance toward healthy options more often—a critical element in both the treatment and prevention of obesity.
During the PCWH program, the Janewskis began considering choices. “We vowed simply not to buy those foods,” says Mary Anne of junk food. “Of course Andrew would pick the chips if they were on the shelf. I couldn’t offer Amy a pear if there was chocolate cake on the counter, or make them go ride their bikes if we were watching TV.” Once unhealthy options were removed from their radar, healthier choices were easier—but not always.
Parents can influence positive lifestyle choices, yet these choices are often sabotaged by ambiguity. University of Calgary researchers published a study earlier this year detailing the truth behind foods marketed to children. Ninety per cent of foods marketed to children were high in sugar, fat or salt, yet over half of the products (62 per cent) had positive label claims—leading parents to think the foods they’re bringing home are nutritious. How parents can make choices when they are misled by messages around them is an important link to solving obesogenic environments.
Dr. Kim Raine is an investigator with Promoting Optimal Weights through Ecological Research (POWER) at the U of A’s CHPS. POWER is a unique team that is pioneering research into behavioural, environmental and social determinants of obesity on several ecological levels, a concentration of research occurring nowhere else in Canada.
Amy and Andrew Janewski. The Janewskis are “changing what we consider normal.” (Bobbi Barbarich)
Raine and her internationally recognized team look at the environment in four ways. “Our behaviours are not purely personal; they’re made in the context of an environment which constantly impacts us,” she says. Obesity has tripled in the last two decades, but genetics has not changed. What has changed is the environment.
The physical environment determines what is available. Fast food is often far easier to buy than fruits and vegetables. Cities are more geared to cars than bikes or walking. Economically, healthy foods are usually more expensive than junk food. “We did a study on campus to see how much per calorie different foods [cost],” says Raine. “Buying a box of 12 doughnuts had an energy cost of 18 cents per 100 calories—about 29 cents per doughnut. On the other hand, salad greens at a cafeteria had an energy cost of eight to nine dollars per 100 calories. This isn’t logical health-wise, but choosing doughnuts over salad makes financial sense.”
Families also have to battle beliefs in the cultural environment—it’s more “normal” to drive the kids to school than to let them walk. “You’re bucking the system if you choose fruits and veggies over pasta or hamburgers. Our expectations have changed,” says Raine. “Of course, families have real concerns like safety, but we’ve come to think it’s better to drive our kids. Is it really better? We need to change what’s normal in our environment, on all levels.” By changing what is expected, parents will set healthier examples for their children.
“Food is a huge challenge,” admits Mary Anne Janewski, shaking her head.
“Even with all our changes, food is definitely the hardest,” agrees Tim. “We know what’s in our bodies, we understand that what we eat goes into our hearts and arteries, but we felt controlled by what is available. We had to realize that junk food is not an option. It’s not a normal thing for us to do anymore.”
Our physical, economic and cultural environments speak closely to the political environment. “It’s the arena in which we need to make the [biggest] changes,” Raine says. “We need policies that restrict fast food restaurants in low income neighbourhoods, roads that encourage cycling and walking, and schools that allow more time for movement. We need to denormalize junk food and inactivity. It has to be normal to make healthy choices.”
Raine warns Albertans should be careful in reading too much into our lower child obesity numbers. “It could be our higher socioeconomic status,” she says. “It could be access to recreational opportunities. There’s no way to tease apart all the factors. But if we don’t make healthy choices normal, our rates will continue to rise.”
Parents have food habits and they also have activity patterns. Moms and dads also have their own perceptions of physical activity and peer interaction. Like adults, many overweight children are embarrassed to draw attention to their bodies during sports, or to be less adept at sports than others. It becomes a vicious cycle—a child is quickly scrutinized and singled out by peers, their willingness to try new things is diminished, new skills are not learned. Lacking skills, the child is again ostracized.
“I hated gym,” says Amy, looking at her thumbs. “I just sat on the side or told the teacher I was sick.”
Tim touches Amy’s knee and adds, “I was resentful to teachers who criticized me.” He empathizes with Andrew and Amy. “It’s hard to put them on a team, to watch them struggle,” he says. “It was stressful to think something may happen—like putting a lamb out to slaughter. As a parent, I had to learn it’s OK for them to be involved and not be superstars. But it also helped when the teachers expected Amy and Andrew to be active, too.”
Treatment is critical for those suffering from being overweight or obese. But at the end of the day, improved education and obesity prevention will have a greater impact on our children’s health.
Since children spend so much of their lives at school, it is critical that schools foster tolerance and acceptance, as well as expectations for participation. In Sep 2005, Alberta Education was the first provincial school authority in Canada to implement a policy requiring 30 minutes of daily physical activity (DPA) for all students in Grades 1–9. Extensive research reveals that healthy students are better able to learn if they’re active. Being active with other kids also forms supportive environments for them to develop healthy, active lifestyle habits. While 30 minutes is only a third of the total daily physical activity recommended by Health Canada, it’s far more than what Albertan students were achieving before the initiative.
Ever Active Schools (EAS) was an integral advocate for DPA and made Alberta Education a model for schools across Canada. EAS works within school communities to help them promote healthy eating, active living and mental well-being. They link with another organization, Schools Come Alive (SCA), which has delivered over 2,400 physical activity workshops to more than 50,000 participants to promote activity in schools. SCA began in 1990 as a project of the Health & Physical Education Council of the Alberta Teachers’ Association, and due to its successful relationship and growth, will be merging with EAS in September.
“Action Schools BC and Living Schools in Ontario are based on Alberta’s EAS model,” explains Doug Gleddie, EAS director. “One of the unique features of EAS is the direct ties to the health and physical education curricula, as well as a focus on changing the school environment to make it as healthy as possible.”
Says Gleddie: “Schools cannot be the ‘be all and end all’ solution to fix childhood obesity. EAS is designed to benefit all children so they have the opportunity to be healthy and make healthy choices—regardless of fitness level, body type or social economic status.”
Schools in Alberta are also addressing access to healthy food. For years, Edmonton Public Schools trustee David Colburn pushed to have junk food banned. While a true ban is impossible right away, Alberta Health & Wellness created the Alberta Nutritional Guidelines for Children & Youth. The first of their kind in Canada, the guidelines give educators and childcare workers strategies and ideas for healthy food choices. The guidelines divide foods into categories of how frequently they should be eaten, leading schools to make nutritious foods accessible and limit availability of poor- quality foods. All foods in the “least healthy” category will be eliminated from schools by 2011, allowing for vendors to complete contracts and phase in healthy foods.
Says Colburn: “Edmonton Public was, to the best of my knowledge, only the second school board in the country to create this policy [Red Deer Public was the first by a couple of weeks]. As a result of the publicity surrounding our policy, I believe we have been a catalyst of change throughout the province.”
Following Veugelers’s lead, the overarching objective of the guidelines is to create environments where the healthy choice is the obvious choice. “Junk foods will always be [available to kids]. Previously, there wasn’t an option for healthy foods,” explains Edi Skoropad, information officer for Alberta Health & Wellness. “We need to empower [schools and facilities] to provide choices so parents and kids will have that option.” And while it’s true that kids will always be able to buy unhealthy foods somewhere, it’s also true that the choices they make away from schools—and later as adults—will employ the decision-making skills they learn in schools. If pop is a “normal” option to school kids, it’ll still be a “normal” option once they’re adults.
No matter how hard a family tries, change will only occur if healthy options are available and parents are willing to promote those options with their children. The Janewskis consider health resources in Alberta to be exceptional, but they still have to define and reach their own goals. “My dream was to go on a family bike ride,” says Mary Anne. “I could never get my kids to come with me. I kept failing and it was very emotional. But we’ve changed our perspective and our environment. And this time, we’re starting to have fun together.”
Bobbi Barbarich is a freelance writer and former pediatric dietitian. She lives and works in Edmonton.
