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Reflections on childhood obesity

Candida Hunt
HENRY Programme Director

Hardly a day goes by without media reports and the publication of academic studies on the subject of obesity - and there is increasing recognition that obesity in babies and young children needs to be taken seriously

We live in a strange world, one in which nearly a billion people suffer from chronic hunger and another billion are obese. Both pose major health risks. In the affluent West in general, and in the US and UK in particular, concern about what has come to be called the "epidemic of obesity" is at an all-time high.
Obesity in childhood invariably features in government health reviews, and the need for wider playground slides and plus-size schoolwear for pre-school children has often hit the headlines - worrying signs of overweight among many young children.

Why focus on babies and toddlers?
Most excess weight in children is gained before a child is five years old, with some signs that the critical period is under two years - for some, as young as three months.1,2
This, of course, means focusing on families and communities, rather than on individual children. Babies and toddlers have little say about what goes into the shopping trolley, what - and how much - is served up for meals and snacks, how much freedom they have to run about, and the unconscious emotional messages they pick up from others around food.
 
It is a truism to say that children learn by what we do rather than what we say, but it sometimes still comes as a surprise that insisting our children eat vegetables when we don't ourselves is unlikely to be effective.

A holistic approach
Since HENRY - Health, Exercise and Nutrition for the Really Young - was established in 2007, we have run training courses for thousands of health and community practitioners. One of the topics we explore is healthy living, to see if there is a consensus about what this means.

We ask everyone to sketch a healthy person, and to note down what they think this person might experience; what they would do, how they might think and feel, and what others might notice about them. In the feedback discussion that follows, we first ask what facial expression trainees have given their drawing. Almost invariably, it is a smiling face. Then we share their ideas, which fall into two distinct but overlapping categories, and generally include:

  • Physical: eating healthily, being active, limiting alcohol, avoiding smoking/recreational drugs/comfort eating, being a healthy weight, having good skin and teeth.
  • Social and emotional: having good supportive relationships with family and friends, work-life balance, having choices/some power in our lives, resilience, confidence, positive self-esteem.

There seems to be a natural understanding that happiness is linked to health. When we ask practitioners how they think the parents they support would respond to this activity, many say that parents would focus more on the physical attributes - and would have little understanding of the social and emotional aspects of health. Our experience tells us the opposite: parents' ideas are very similar to our own - and they draw smiling faces too.

Why is it, then, that healthy lifestyle initiatives tend to focus on diet and exercise, leaving out the crucial insight that food is widely used to promote feelings of wellbeing? Food has such symbolic significance that we cannot afford to think of it simply in terms of nutrition.

The psychoactive benefits of food are often overlooked, but it is not at all surprising that our relationship with food can be a complex one. As Raymond Tallis says, "Food is inseparable from our earliest and most intense relationships. Breastfeeding provides all forms of nurture at once … and the giving of food is one of the most primordial of gift relationships. Food addicts are always making gifts to themselves, perhaps making up for a world that seems to withhold that emotional nourishment for which we human beings hunger almost as much as for nutriment."3

When we bear this in mind, the belief that behaviour change is likely to result simply from advising people about what food is healthy and what is not begins to feel faintly ridiculous. It is a simplistic response to a multi-faceted and complex problem, whose solutions (if any are to be found) demand a much more
holistic approach.

Pointers from research
In 2009 Professor Mary Rudolf, consultant paediatrician and professor of child health at the University of Leeds, and with many years' experience in the field of childhood obesity, undertook a commission from the Department of Health to review international evidence on the prevention and treatment of obesity in families with young children. The framework that resulted from this work identified five areas that are needed to support the development of a healthy lifestyle from the start of life.4 These are:

  • Parenting skills.
  • Eating and feeding behaviour.
  • Nutrition.
  • Play, activity and sleep.
  • Practitioners' effectiveness.

There are clear indications that the patterns and habits we adopt around food are as important as what we actually eat. In families the quality of parenting - which essentially includes emotional responsiveness, the wellbeing of family members and strategies for managing children's behaviour - play a vital part. Some families manage all this for themselves, but others need greater support, and this is where practitioners' effectiveness can make a real difference.

Practitioners' effectiveness: messengers and messages
What makes an effective practitioner? In families needing support to adopt a healthy family lifestyle, the quality of the relationship between helpers and parents is also of crucial importance.5,6 Our experience with HENRY reflects the research findings, and I believe points a way ahead if we are to work within this broad framework on family lifestyles. The suggestions that follow are not limited to supporting young families around lifestyle and weight; they draw on well-established models of support, and reflect many years' experience of hoping to help people with a range of different issues that preceded my involvement in child obesity.

Practitioners are often expected to be catalysts for change, and many are still trained to believe that their extra expertise will enable them to dispense advice and all will be well. Traditional training often focuses (rightly) on knowledge and information, and pays less attention (wrongly) to the quality of a helping relationship and therapeutic approaches to support it.
Many health professionals lack confidence in tackling the question of weight in general and in recognising that, in babies and toddlers in particular, it is a sensitive issue. In this they are right to be wary, as being given unwanted, unneeded or insensitive advice can be utterly disempowering.

I experienced this myself when, in the course of a routine eye test a few years ago, I was diagnosed with a long-term condition that will lead to deteriorating eyesight. As I made my way through the system from optician to eye hospital, I was advised by every health professional I encountered that I should improve my diet, eating more colourful fruit and vegetables, particularly leafy green vegetables. Nobody asked me what I was already eating.

Finally, in exasperation, I cracked and went on the attack, pointing out that I am a vegetarian with a diet based on fruit and veg, and that I run an obesity prevention programme! What was even more difficult to cope with was the lack of empathy or understanding; at no point did any of these well qualified professionals offer emotional support or ask me how I felt about what was a devastating diagnosis. I wasn't a person - I was a prognosis.

Therapeutic approaches take as a fundamental tenet that, in a helping relationship, the key to behaviour change is the relationship itself, which relies on empathy, listening skills and a real desire to understand the other person's perspective, to value them as they are. In this situation, the catalyst for change is the messenger. If change were easy, the message alone would be enough; armed with the information we need, we would change. For most of us, however, this seldom happens. (If it did, nobody would smoke, and almost everyone would be a healthy weight.) Because our habits are etched into our brains and our bodies, it is much easier to do what we've always done than to unlearn what we know and train ourselves to do something different.

The question of motivation
Change takes real motivation that needs to be our own, and not that of a professional with targets to meet (or, indeed, of a facilitator running a training course!). When motivation is intrinsic, we may seek advice and are likely to pay heed to it. But when someone else urges us to change because they think we should, there is a risk that our willingness to change may be reduced rather than boosted.

With the best of intentions, practitioners will often recommend lifestyle changes to families and become frustrated when the client is "resistant" or does not "comply" by following the advice they have been given. The language of resistance/compliance is often used, and it offers a valuable clue to what may be going on. Expecting obedience indicates a power imbalance, with the practitioner in the position of a superior adult and the client in the position of an inferior child. It is no wonder that unsolicited advice, however valid, is likely to be experienced as criticism, which is more often than not a demotivating emotion.

Motivational interviewing offers a helpful way of thinking about change: when a person is ambivalent about making changes in their life, and someone else argues for change they will usually defend themselves by arguing against it, resisting the sense of being coerced that attempts at persuasion may bring, and maintaining the status quo.7

Another way to think about change is in terms of a combination of motivation and confidence (see Figure 1). This model shows - albeit simplistically - four pairings that reflect the likelihood of change taking place. Something needs to matter to us for us to make the effort to change, and we also need to believe we have a chance of succeeding. When motivation and confidence are both strong, action is likely to follow; when one or other - or both - is lacking, it is not. Help that does not take this into account is likely to backfire.

[[Fig 1 child obesity]]

To be truly helpful, practitioners need to discover what is important to a client, what they themselves would like to change, and how. Building a trusting relationship allows time to explore fully the client or family's context, strengths, aspirations and challenges, in a way that builds confidence and helps them find their own motivation to change.

When a goal and the steps to reach it are chosen by the client, the investment in change becomes their own, and they will begin to believe in their ability to achieve it. This is working in a true partnership - walking alongside the person we support, and helping them find their own way rather than exhorting them to adopt ours.

The effectiveness of this approach was beautifully described by a parent at the end of one of the eight-week "Let's Get Healthy With HENRY" courses run by facilitators who have trained with us. She said: "The ladies who ran the course were so friendly, made the course very enjoyable and listened to all our ideas, and only gave us advice if we really needed it. They didn't tell us we have to make changes; but it made me want to."

References

  1. Gardner DS, Hosking J, Metcalf BS, Jeffery AN, Voss LD, Wilkin TJ. Contribution of early weight gain to childhood overweight and metabolic health: a longitudinal study (EarlyBird 36). Pediatrics 2009;123(1):e67-73.
  2. Harrington JW et al. Identifying the "tipping point" age for overweight pediatric patients. Clin Pediatr 2010;49(7):638-43.
  3.  Tallis R. Hunger (The Art of Living). Stocksfield: Acumen Publishing 2008
  4.  Rudolf M. Tackling Obesity through the Healthy Child Programme: A Framework for Action. Available from: www.noo.org.uk/uploads/doc/vid_4865_rudolf_TacklingObesity1_210110.pdf
  5.  Braun D, Davis H, Mansfield P. How Helping Works: Towards a Shared Model of Process. London: Parentline Plus; 2006
  6.  Hunt C, Rudolf M. Tackling Child Obesity with HENRY: a handbook for community and health practitioners. London: CPHVA; 2008.
  7.  Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. New York/London: The Guilford Press; 2002.