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Tackling childhood obesity with HENRY

Candida Hunt
HENRY Programme Director

The HENRY (Health, Exercise, Nutrition for the Really Young) programme combines successful approaches from several disciplines, working in partnership through empathy and solution-focused support to address the problem of childhood obesity in the under-fives. Candida Hunt explains how it works ...

When I tell people that I work with a child obesity initiative, most readily offer me an explanation for why it has become such a problem, including:

  • "Obesity's just a question of being lazy".
  • "It's because children sit at their computers or watch TV all the time and don't get any exercise".
  • "Parents can't be bothered to cook properly nowadays".
  • "It's the fault of the junk food industry".
  • "People don't have any self-discipline any more".
  • "The streets aren't safe nowadays so children can't go out to play".
  • "Eating's an addiction, like smoking".
  • "The school playing fields have all been sold off, the government's responsible".

All these answers are partly right, and none of them is wholly right, because, of course, child obesity - like weight issues among adults - has many possible causes. These may be genetic, familial, habitual, emotional, social, economic, cultural, societal, and they combine to create the "obesogenic" environment in which we live.

Who are these overweight people with their overweight children? Some of them are … us! The 2009 Department of Health report Healthy Weight Healthy Lives … One Year On suggests that it is time we put ourselves, as well as our patients, on the weighing scales, reporting that of the 1.2 million people employed by the NHS, 300,000 are obese and a further 400,000 are overweight.1 Many of the practitioners we meet on HENRY training courses struggle with just the same lifestyle issues in their families as clients and patients.

Why does it matter?
The evidence for needing to tackle obesity in the very young - even in babies - is quite recent. A systematic review published in 2005 identified that a high birth weight, rapid weight gain and obesity in the first few months of life are linked to the development of long-term obesity, with all its associated risks for health.2 In December 2009, the NHS Information Centre reported that one in five children start school overweight or obese. The statistics worsen as they move through primary school.3

The need to think differently about early weight gain is also reflected in the new World Health Organization 0-4 years growth charts introduced in 2009. The new charts, based on optimal growth for breastfed babies worldwide, rather than average growth among breastfed/bottle-fed babies, will make weight patterns look different, with only one in 200 children falling below the second centile for weight after six months, and twice as many above the 98th centile.4

Many community practitioners still focus on weight gain as an indicator of a baby's health to such an extent that anxious parents are encouraged to overfeed their baby. One of the advantages of breastfeeding is that it is harder to overfeed as we do not know exactly how much the baby is, or should be, taking. We have to trust the baby to regulate - as they naturally do - their own feelings of hunger and fullness. We may need to reconsider the way we support parents in the early weeks and months, and also readjust our sense of what a healthy baby looks like: probably rather less plump than we think.

Among obese children, presenting health problems are both physical and emotional or behavioural, including asthma, sleep disorders, orthopaedic complications, type 2 diabetes, low self-esteem and impaired quality of life. More worrying still are hidden problems, such as metabolic syndrome, impaired glucose tolerance and non-alcoholic fatty liver disease.5

Addressing weight issues with anyone can be a delicate matter. When it comes to babies and young children, we need to be even more sensitive - parents are especially vulnerable to criticism. Information and advice may be helpful, or may overwhelm. They may answer specific questions, or fail to address underlying issues. As practitioners we are trained to identify problems and issues, and tend to try to fix these; we are, after all, the experts.

Listening to the frustrations of both practitioners and parents with young children who are overweight, it is clear that the advice-giving expert model is often not effective. The need to find alternative ways of tackling this important health issue right from the start (with 0-5s) has resulted in HENRY (Health, Exercise, Nutrition for the Really Young), which combines in a new way successful approaches from several disciplines, working in partnership through empathy and solution-focused support.

The Family Partnership Model
An approach that truly seeks to establish a partnership between parent and practitioner is unusual.6 Here, the intention is to identify and highlight the parent's own knowledge, strengths and skills, to explore and build on their ideas rather than imposing our agenda on them - to walk alongside them rather than trying to lead. There is a real art in listening more than we talk, in resisting the temptation to jump in with premature advice rather than helping the parent discover what will work for them and supporting them in putting into practice changes they choose to make.

Empathy: a catalyst for change
Empathy is often described as "putting yourself in someone else's shoes". This is not a very helpful - nor accurate - definition. If I put myself in someone else's shoes I remember how I have felt or imagine how I would feel in their situation. This tells me nothing about how they themselves experience their situation - their reaction to an event or set of circumstances may be quite different from mine.

True empathy is different. It requires me to set myself aside and instead tune in as fully as I can to the other person. This emotional attunement is a sensitivity to the subtle nuances of feeling that are experienced by someone else. Everyday kindness and sympathy are relatively easy to offer; really sensing someone else's grief, anger, loneliness, bewilderment, despair, fear, joy or delight, and being fully present to them without getting in the way, is a skill of a quite different order.

To be heard empathically is a precious gift. We feel valued, cared for, understood. And by some strange alchemy, when we are accepted as we are, it becomes easier to consider taking the risk to be different: it can help us find the motivation to change.

[[Box 1 obesity]]

From problem to solution
Where do we need a client's expertise to lie? In their difficulties or in the resolution of those difficulties? Here is a simple example. A mother who is trying to get her toddler to eat vegetables reports to you that in the last week, although he ate carrots at one meal and peas at another, they had a major battle when he wouldn't eat the parsnips she'd cooked for him. He had a tantrum and threw the dish on the floor - and then refused to try the sweetcorn too.

Problem-focused response: "Oh dear, toddlers are often difficult about accepting new foods and he's really trying it on with you at the moment, isn't he? Has he eaten parsnips before? Have you tried mashing them? Was the sweetcorn mixed in with the parsnips - it might be better to try them a different way another time."

Solution-focused response: "You seem a bit discouraged about how things are going. I remember a few weeks ago that he made a fuss about all the vegetables you offered him, so to manage both carrots and peas sounds like real progress to me. I'd love to hear more about what you did at those meals that helped him to try them so I can get a sense of what's working well for you - and for him."

Helping hands: the HENRY approach
We believe that the messenger is just as important as the message: that if we are to give effective support to parents around family lifestyle issues, our attitudes and skills are as important as our knowledge. When I talk at conferences I ask the audience to raise their hand if they know the recommended number of daily portions of fruit and vegetables. Everyone's hand shoots up.

Then I ask - an honesty test! - those who actually eat five or more portions each day to raise their hands. Between a quarter and a third of hands go up. So even what might be regarded as a group of experts - health and community practitioners - is not putting theory into practice, proving that often information is not enough to lead to behaviour change towards a healthy lifestyle.

When we are working with young families, the usual healthy lifestyle messages need to be combined with parenting support and an attitude that builds parents' confidence rather than undermining it. A child refusing to eat vegetables - as in the example given above - is likely to be a parenting issue rather than a dietary issue, and will not be an isolated difficulty. Box 1 gives the key elements in the HENRY approach, in which there is as great an emphasis on process (the "how") as there is on content (the "what").

Many practitioners are reluctant to raise the issue of weight with families with young children, lacking confidence that they have the skills to make matters better rather than worse. We believe - as a result of feedback from our training courses - that the HENRY approach helps to give practitioners the confidence they need to work effectively in addressing this important health issue.

References
1. Department of Health. Healthy Weight Healthy Lives … One Year On. London: DH; 2008.
2. Baird J, Fisher D, Lucas P, Kleijnen J, Roberts H, Law C. Being big or growing fast: systematic review of size and growth in infancy and later obesity. BMJ 2005;331:929.
3. NHS Information Centre. National Child Measurement Programme: England, 2008/09 school year. London: NHS Information Centre; 2009.
4. Royal College of Paediatrics and Child Health. UK-WHO Growth Charts: Early Years. Available from: www.growthcharts.rcpch.ac.uk
5. Hunt C, Rudolf M. Tackling Child Obesity with HENRY: A handbook for community and health practitioners. London: CPHVA; 2008.
6. Davis H, Day C, Bidmead C. Working in Partnership with Parents: the Parent Advisor Model. London: Harcourt Assessment; 2002.