CHILDHOOD OBESITY: Good News Amid the Bad

Tracey Hessel, MD

After decades of ever-worsening statistics about the weight of our children, a few pieces of good news have recently emerged, along with evidence that people are starting to take the childhood obesity epidemic seriously. Nonetheless, we still have a long way to go to significantly impact a phenomenon that is affecting a quarter of Marin’s children.

According to a recent statewide study, we may be starting to make small amounts of headway toward reducing the scope of the problem.[1] Researchers found that the prevalence of overweight or obesity in 5th, 7th and 9th graders in California decreased by 1.1% from 2005 to 2010. However, 38& of the children statewide are still overweight or obese--triple the rate of 30 years ago. Marin County, with 24.9% of children overweight or obese, had the lowest level in the state, although the local rate has increased over the past five years.

Other recent studies have highlighted the dramatic disparities in health and well-being between different geographic regions within Marin.[2,3] Not surprisingly, these disparities are also true for overweight and obesity, with children living in Novato and San Rafael having rates 10% higher than those of the county overall.

The children we treat at Marin Community Clinics don’t have private insurance, and most face multiple economic and social barriers to making healthy lifestyle changes. A large part of my clinic day is spent counseling children and their families about adopting changes in their daily lives that will improve their fitness and reduce or at least stabilize their weight. The basic messages are simple: limit sugared beverages, increase fruits and vegetables, limit fast food, be active every day, and decrease screen time. But, as is true of most of the behavioral changes recommended to our patients young and old alike, these simple concepts prove difficult to adopt and sustain.

Over the past decade, I have observed a positive change in awareness of childhood obesity among the families I treat. Most are concerned when their child is identified as being overweight and often have already taken steps to reduce sodas and junk food in their diets. However, they may need help seeing past the marketing to recognize similar sources of excess calories, for example in sport drinks, juices, and other more healthy-appearing options.

One of the more surprising factors limiting families’ success in adopting nutritious diets is the “food desert”: a geographic area without easy access to affordable, healthy foods. Within Marin County, several areas of Novato and San Rafael have been classified as food deserts by the U.S. Department of Agriculture. The typical local options for families who live in these areas are limited to convenience stores, liquor stores and fast-food restaurants. Making healthy choices for residents of these areas is especially challenging.

Another factor that impacts many children is “food insecurity”: lacking the financial resources to regularly purchase food. In the most severe situations, food insecurity can result in hunger. In other cases, there is a strong relationship between food insecurity and overweight, along with consequences such as diabetes. Studies of at-risk populations have shown that people with food insecurity often limit the variety of the food they purchase.[4] They end up concentrating on lower-cost, energy-dense but nutritionally lacking foods, such as refined carbohydrates with added sugars, fats and salts.

From the parents I work with who are motivated to improve the diets of their children despite these challenges, I have also heard frustration that their ability to impact their child’s overall health is limited. A growing number of children in Marin (upwards of 50% in San Rafael Elementary and Sausalito/Marin City school districts) qualify for the free meal program. Many of these children receive both breakfast and lunch at their school. If they receive additional instruction or childcare in an after-school program, they will also likely receive an additional snack at school. Thus, the nutritional content of those school meals contributes greatly to their overall health.

Even though school meals meet minimum federal nutritional guidelines, they leave much to be desired in terms of providing fresh, healthy and minimally processed foods to our children. Local schools have recently made some positive efforts to improve their nutritional offerings and opportunities for physical activity. School districts have adopted wellness policies that set guidelines around physical activity; establish nutritional expectations for foods sold at school or used in classroom parties; and define minimum standards for the health-education curriculum.

In addition, several programs provide healthy foods to supplement school meals. San Rafael elementary schools, for example, now have salad bars with fresh produce. Some schools have their own vegetable gardens or participate in Farm to School programs that promote the use of local produce and teach students about the origins of their food. Nonetheless, the biggest obstacle to improving the actual meal offerings is the limited funding for school lunches. The budget per student per meal, including milk, is approximately one dollar.

Of all of the unhealthy behaviors I address with children, the one I have the most trouble impacting is lack of exercise. The goal of having children be active every day seems like it should be easy to attain. But exercise, like food, is subject to socioeconomic constraints. Few of the elementary school students in Marin participate in a physical education class every day; some participate only once a week. Moreover, parents with limited means often report being unable to afford the equipment and uniforms needed to enroll their children in sports. Even outside of school, parents sometimes feel that it is unsafe to let their children play in their crime-ridden neighborhoods.

As I work with families, I experience what is being reported nationally by those trying to address the problem of overweight and obesity. There are successes, modest for my practice overall, but thrilling for children and families who are able to make significant changes, experience improved weight and fitness, and integrate healthy habits into their lives. Despite these small successes, I am convinced that truly impacting and reversing the epidemic of childhood obesity will require more than any of us can offer through individual counseling in the office setting. It will require changes in our schools, our neighborhoods, and our public policies.

While making healthy lifestyle choices is ultimately up to the individual (or the individual’s parents, depending on their age), it is important to acknowledge the challenges created by misleading marketing, limited access to affordable and nutritious foods, and lack of opportunities to play safely. We can’t force changes upon individuals, but we can work to create an environment conducive to success. As stated by the Robert Wood Johnson Foundation, “[T]he environments we live in and the public policies our leaders enact directly impact the foods our children eat and how much activity they get.”[5]

This year, the Marin County Department of Health and Human Services assembled a diverse group of agencies throughout the community who work with children and families to promote the Healthy Eating and Active Living (HEAL) program. Through HEAL, a strategic plan is being developed to impact health in Marin through improved nutrition and physical activity. This is an exciting development, but HEAL will need the advocacy and support of our colleagues and neighbors to prioritize the creation of healthier communities for all our children.

As with an individual or a family, how we choose to spend our money reflects our values and priorities. With California’s per capita spending on education 47th in the nation, our schools don’t have a lot to work with. Physical education is an unfunded mandate; in most schools it is provided by PTAs, school foundations or outside grants. We’ve budgeted just one dollar per meal to provide food to children who are most at risk for food insecurity.

With a quarter of Marin’s children overweight or obese, this is the first generation that may have a shorter life expectancy than their parents. We can change that, but it will take a commitment to creating healthier communities throughout Marin. In a county known for its wealth and natural beauty, it doesn’t seem like such a stretch to imagine a Marin where children regularly receive nutritious meals and participate in daily vigorous activity--where all communities have access to parks, accessible sport programs, bike paths, and markets with affordable, nutritious foods.

 

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Dr. Hessel is the lead pediatrician at Marin Community Clinics.

Email: thessel@marinclinic.org

References

1. Babey SH, et al, A Patchwork of Progress: Changes in Overweight and Obesity Among California 5th, 7th, and 9th Graders, 2005-2010, UCLA Center for Health Policy Research and the California Center for Public Health Advocacy (November 2011).

2. Burd-Sharps S, Lewis K, “A Portrait of Marin,” Measure of America (2012).

3. Gihuly K, et al, “Marin Healthy Homes Project,” Legal Aid of Marin & Health Impact Partners (2012).

4. Casey PH, et al, “Association of child and household food insecurity with childhood overweight status,” Pediatrics, 118:e1406-13 (2006).

5. Robert Wood Johnson Foundation, “Childhood obesity,” www.rwjf.org (2012).