Jack Sprat could eat no fat
His wife could eat no lean
Success resembles a fat cat
Obesity starts before they wean
Childhood obesity is increasing at an alarming rate in Canada. The number of overweight and obese children jumped from 9-11% in 1986 to 33% in 1996 for boys aged 7-13 years and from 13% to 27% for girls aged 7-13 years.1 But when does obesity actually start for these children? Our childhood obesity prevention research team at the Faculty of Nursing of the University of Alberta wanted to know what is recognized about causes of obesogenesis during pregnancy and infancy and its prevention. The study discovered not only solid pathophysiological determinants of childhood obesity but also a culture of obesity that is burgeoning in this country. Why is this happening today? Society promotes an acceptability of obesity within certain sectors. In many ethnic groups found in Canada, people's success is measured by the size of their girth; overweight babies are perceived as healthy. How can we stop this trend? When should we start? Given there are so many bio-socio-economic factors to consider, where do we start? It took Katherine Moore to understand the connection between my research interest in early childhood obesity prevention and WOCN when she kindly invited me to write the guest editorial for this special bariatric issue. It is clear that obesity is comorbid with multiple bariatric conditions that have their beginnings in childhood and are related to how we eat, what we eat, and how we burn off the calories. These activities are learned at our mothers' knees.
Rapid weight gain by low-birth-weight babies (< 2500 g) in the first 4 months of life is associated with an increased risk of being overweight by age 72; 77% of obese children aged 7-13 years remain obese as adults.3 Suboptimal fetal and infant growth and overnutrition and undernutrition may further contribute to risk of chronic diseases such as obesity, type 2 diabetes, coronary heart disease, stroke, and high blood pressure or hypertension. High-birth-weight babies (> 4000 g) are often born to mothers who are diagnosed with gestational diabetes or are at risk for developing type 2 diabetes. The greatest variation in rates of weight gain in early infancy is when infants may show significant "catch-up" or "catch down" growth. Because early obesity is a predictor for adolescent or adult obesity, there are tremendous implications for early prevention of childhood obesity, including nutrition and safety issues and other bariatric concerns, such as wound healing. We must do something to stem this trend toward obesity, starting right at the beginning of life.
Childhood obesity has multiple causes that include a genetic predisposition and lifestyle habits, such as minimal physical activity and poor dietary habits during pregnancy, and in childhood. Given the escalating costs of healthcare, the increase in childhood obesity in our society will place a bigger burden on an already overextended healthcare system. In addition, these children who are obese will experience a reduced quality of life as they age.
Already, millions of dollars have been expended to present healthy lifestyle and nutritional models to the public. We know that later childhood-onset and adult-onset chronic cardiovascular diseases and diabetes are not limited to those in poor financial conditions. The majority of people who are obese, however, are found in low socioeconomic settings4 where they lack effective coping skills and financial resources to adapt their life style toward what has healthier health outcomes. A large portion lives on social assistance that is barely adequate for subsistence living. Mothers need to have a fixed address before they can access a social assistance check. It is appalling, therefore, that welfare systems ensure that families have access to television sets before providing coupons to ensure healthy eating and active recreation activities.
Our challenge is to at least address the following factors at individual, community, and policy levels to effect desirable changes in lifestyle:
[black small square]Low socioeconomic status (LSES) gives rise to social conditions in which access to foods and adequate activity are constrained by low income and lower education of mothers (in particular).
[black small square]High stress persists for LSES populations when trying to make ends meet amid limited social support conditions.
[black small square]Pregnancy and childbirth occur within a family setting. When resources are scarce, pregnant women often forego feeding themselves if doing so means that their older children will have adequate food, while inadvertently starving the latest family addition.
[black small square]Urban and risky lifestyles combined with a LSES foster low activity levels, especially within a culture where the only entertainment may be perceived to be a television set. Walking is eschewed in favor of taking a bus to travel short distances.
Cultural perceptions about the meaning of fatness or thinness are passed down through the generations5 and to new immigrants. Social interactions and support systems, communities, and economic standing level combine with underlying pathophysiology to affect the obesity epidemic in multiple ways. How a person reacts to life stressors affects his or her health and outlook on life. Stress and risky lifestyle behaviors can contribute to illness directly or indirectly. People living with LSES are constantly living under the stress of making ends meet.
Most LSES mothers have views about the definition, cause, and management of obesity that differ greatly from those of most healthcare professionals. This perception gap is even greater between what LSES mothers consider a healthy weight for their children compared with that deemed healthy by healthcare professionals. This gap must be bridged by the professionals.6 The American Academy of Pediatrics, however, has focused primarily on treatment recommendations and not on combined medical, psychological, and emotional evaluation or barriers to care.7
The gap must be better understood to determine how intervention programs can be effectively delivered. One of the barriers to obesity prevention is a lack of practical prevention skills and public health training as regular parts of medical education. A multidisciplinary health team approach to obesity prevention program initiatives is required to address childhood obesity, particularly in the prenatal and early infancy time periods. Little is known about why parents choose to pay attention or to ignore the advice of healthcare clinicians in the areas of obesity prevention, particularly in the younger age group.
New approaches are needed to understand the different perceptions that are held by clients and healthcare professionals. We need to know more about why families seek treatment or where to direct our clinical practice when diagnosing and treating childhood obesity. We need to work with mothers as active partners if interventions are to succeed. It is clear that we need to start preventing obesogenesis from an early age if we are to stem the trend toward obesity and its comorbid conditions. We cannot afford to wait to take action until the children have stopped learning nursery rhymes!!
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