Thirty years ago I had an experience in the office that influenced my approach to obesity for the rest of my career. The patient was a 4-year-old whom I had been seeing since her birth. At her annual well-child visit her weight had jumped up significantly from the previous year’s visit. She appeared well, but the change in her growth trajectory prompted a bit more in-depth history taking.
It turned out that finances had forced the family to employ one of the child’s grandmothers as the day care provider. Unfortunately, this grandmother’s passion was cooking and she was particularly adept at baking. She had no other hobbies and a sore hip limited her mobility, so she seldom went outside. When I eventually met her she was a cheerful, overweight, and delightful woman.
Dr. William G. Wilkoff
Deconstructing this obesogenic environment without disrupting this otherwise healthy family was an exercise that required tact, patience, and creativity. Fortunately, the young girl’s mother had already harbored some concerns about her child’s weight and was more than willing to participate in this environmental re-engineering project. It’s a long story, but she and I achieved our goals and the child eventually coasted back toward her previous growth curve.
I have always suspected that this scenario is being replayed hundreds of thousands of time across this country. But, sadly most don’t share this one’s happy ending. Parents don’t alway perceive the seriousness of the problem. The economic hurdles are often too steep to overcome, even when the most creative minds are involved.
How prevalent are obesogenic day care environments? We certainly know childhood obesity is a problem and the statistics in the preschool age group are particularly concerning. More than 14 million children are in non-parental early care and education programs; these environments would seem to be a logical place to target our prevention strategies. Understandably, there seems to be a hesitancy to point fingers, but how many day care providers are similar to the well-intentioned grandmother in the scenario I described? We must at least suspect that the example set by the adults in the preschool and day care environment might be having some influence on the children under their care.
There has been some research that sheds some light on this question. A paper from the University of Oklahoma has looked at the predictors of overweight and obesity in early care and education (ECE) teachers in hopes of “finding modifiable opportunities to enhance the health of this critical workforce.” In their paper, the investigators refer to other research that has found the prevalence of overweight and obesity among ECE teachers is higher than our national average and their waist circumference is significantly greater than the standard recommendation for women.
A study from Norway has looked at the association between preschool staff’s activity level and that of the children under their care using accelerometers. This particular investigation couldn’t determine whether it was the staff’s activity level that influenced the children or vice versa because it wasn’t an observational study. Common sense would lead one to believe it was the staff’s relative inactivity that was being reflected in the children’s.
It is interesting that in this Norwegian study when the teachers were asked about their attitudes toward activity and their self-perception of their own activity, there was no relationship between the staff’s and the children’s level of activity. In other words, the educators and caregivers bought into the importance of activity but had difficulty translating this philosophy into own behavior.
So where does this leave us? It turns out my experience decades ago was not a one-off event, but instead represents the tip of very large iceberg. Should we immediately create a system of day care provider boot camps? Let’s remember that each educator and caregiver is one of us. They may be slight outliers but not a group of individuals deserving of forced marches and half-rations to get them in shape.
ECEs have listened to the same message we have all heard about diet and activity and their importance for a child’s health. It’s for their own health and that of their charges. This could be as simple as providing accelerometers or step-counting smartwatches. Or, by having physical educators perform on-site audits that could then be used to create site-specific plans for increasing both teacher and student activity.
Modifying the educators’ diet is a more complex procedure and can quickly become entangled in the socio-economic background of each individual teacher. A healthy diet is not always equally available to everyone. The solution may involve providing the teachers with food to be eaten at work and to be prepared at home. But, creative answers can be found if we look for them.
Before we get too far down the obesity-is-a-disease pathway, we must take a closer look at the role the early care and early school milieu are playing in the obesity problem. A little common sense behavior modification when children are in the controlled environment of school/day care may allow us to be less reliant on the those new wonder drugs in the long run.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.