IJE Advance Access originally published online on August 31, 2006
International Journal of Epidemiology 2006 35(5):1369-1370; doi:10.1093/ije/dyl198
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Book Review |
Childhood obesity—contemporary issues. N Cameron, N G Norgan and G T H Ellison (eds). Boca Raton: Society for the Study of Human Biology Series, CRC Taylor Francis, 2006, pp. 272, £49.99/$89.95. ISBN 0-8493-2857-8.
E-mail: anita_groos{at}health.qld.gov.au
Childhood obesity—contemporary issues is based on a symposium on childhood obesity, which focused on the problem in the UK, and was auspiced by the Society for the Study of Human Biology in December 2003. The resultant text provides a comprehensive overview of epidemiological and research evidence to date, plus individual developmental project experiences, with extensive references.
Laurel Edmunds notes that health professionals have been found to feel a lack of competence with respect to childhood obesity (p. 76), and the growing epidemic in many areas of the world is clearly the basis for increasing concern and interest. On a global level the rapid increase in obesity found in lower-income and middle-income developing countries, with a rate of change that is greater than in high-income countries, and the shift towards the poor on a worldwide basis is cause for alarm. However, I believe, one of the biggest challenges remains in trying to simultaneously address the individual and treatment or obesity management focus, almost forcing health professionals to compete with the latest magazine article, reality television programme, or celebrity diet; and true primary prevention or population health approaches. Responsibility for this global issue clearly rests with society as a whole and will require multi-sectoral collaborations, integrated approaches at the community level, and considerable political will.
The book provides a good overview of technical issues in assessment, health impact, and research domains as well as realities for families and children impacted by childhood obesity gained from in-depth interviews. Part I covers the scope and impact of childhood obesity including measurement and standards issues, which remind us that we have not yet achieved an agreed universal diagnostic definition of obesity, and outlines many of the psychological and social issues around self-competence and self-esteem.
School settings have long been recommended as an excellent health promotion environment, where ‘promoting healthy eating can be an integral and acceptable component of the school curriculum’ (p. 229) and suggestions that active travel may encourage higher physical activity over the whole day are encouraging. However, chapters four and five also highlight that some physical activity opportunities can also be a source of victimization and bullying, which may in fact provide a platform for eroding the self-worth and competence of obese young people. And that ‘obese children tend to be less active at times when activity is more likely to be determined by free choice, particularly outside of school’ (p. 125). This suggests that the school probably remains an excellent context for prevention and protection, but we are also faced with the question of how to integrate larger psychosocial issues for a growing proportion of children now likely to be overweight or obese. This is particularly the case given that in the US, 40% of children are now either obese or in danger of becoming obese, and all indications are that rates of increase in most countries are about 4% per 10 years or even higher.
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Part II outlines the role of biological and social processes in the aetiology of childhood obesity and also concludes that complexity and multiple determinants of children's behaviour are a vital part of the picture. Although there is clear consensus that high energy intake and low energy expenditure are the causes of obesity, dietary and activity prescriptions have failed to effectively impact on childhood obesity prevention to date. Assessment issues of food intake and physical activity clearly restrict the conclusions that can be drawn from much of the research on best investments and interventions in this area. The systematic reviews included under the prevention and treatment heading in Part III, seek to address this but again conclude that there is a remarkable lack of good quality evidence and ‘simple, effective, and generalisable interventions do not exist at present’ (p. 209).
Increasingly attention is being focused on early life and bringing about improvements in child health and development independent of obesity, as well as targeting modifiable behaviours that are likely to be related to obesity. Critical periods are generally accepted as being: life in utero, infancy, the pre-school period before the adiposity rebound, and adolescence (p. 217). Reducing sedentary behaviours and sugar-sweetened drink consumption and increasing breastfeeding would be excellent starting points in this context, and maternal smoking during pregnancy could be added for an even broader perspective. However, much of this again comes back to social and political will in terms of relationships with the food and advertising industry for sugar-sweetened drinks, access to TV and computer time vs increased opportunities for a range of physical activity options, and breastfeeding facilities and policies that support families.
In relation to efforts to increase fruit and vegetable intake among children, chapter 15 suggests that interventions can have a small but significant positive effect. It seems to be important to treat fruit and vegetables separately, provide knowledge and access, as well as reducing the emphasis on health. Yet child-relevant and ostensibly exciting fruit and vegetable promotions to date have not been found to be any more effective than other approaches (p. 243). Conversely, the creative strategies used by food advertising to target children do appear to be successful and generally use hedonistic appeals including taste, humour, action-adventure, and fun (p. 257). Although many of the studies examining food promotion to children again have methodological issues that weaken conclusions, there are some that clearly demonstrated a link between advertising and children's food knowledge, preferences, behaviour, and diet or health status. Laura McDermot, Martine Stead and Gerard Hastings conclude that ‘advertising can shift children's preferences not just between different brands of chocolate cookies, but between chocolate cookies and fruit’ (p. 262).
As a population health practitioner who is still well short of the evidence-based practice answers in terms of where to invest energy and time, I would like to concur and return to the conclusions of Penny Gordon-Larsen and Barry Popkin in their early chapter on global perspectives on adolescent obesity. ‘Greater attention must be paid to research on economic, environmental, and social determinants of obesity in children and adolescents’ (p. 22). How to achieve change at that level while also dealing with the treatment imperatives and mental health of a rapidly growing number of obese children remains the challenge for health professionals at all stages of the continuum of care, families, communities, industry, and society as a whole. While health professionals wait for the outcomes of ongoing large randomized controlled trials occurring in the US, which will produce more evidence in 5–10 years time, I would also like to support the ‘do no harm’ and other principles put forward by Whitaker1 and supported by John Reilly in chapter 14.
For those seeking to explore culturally relevant approaches and develop research that can contribute to the evidence in this field, which does need urgent and innovative measures, Childhood obesity—contemporary issues provides an excellent overview. The comment by one study participant clearly illustrates how important this effort is from the human and child perspective.
‘It's like being middle aged as a child. It's like, well yeah, it's like being old before your time. You can't ... you can't do everything that everybody else can do ...’ (p. 55).
Reference
1 Whitaker RC. Obesity prevention in primary care: four behaviours to target, Arch Pediatr Adolesc Med 2003;151:725–27.
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