Research Feature

Countering the Lollipop Lifestyle

Modern conveniences like junk food and cell phones take their toll on kids as childhood obesity rates skyrocket

by Tamar Nordenberg

Countering the Lollipop Lifestyle

When she was a child, healthy eating and exercise were matter-of-course for kids, First Lady Michelle Obama noted in a recent address during her ongoing crusade against childhood obesity.

"Today, it's the exact opposite," the healthy-weight advocate commented, citing lifestyle shifts in recent decades such as longer hours in front of the TV, computer games and texting becoming default pastimes over kickball and jump rope, and fast food becoming an everyday convenience over more expensive fruits and vegetables.

The evolution of priorities, toward empty calories and away from exercise, helps explain a skyrocketing obesity rate among U.S. children: Childhood obesity's prevalence has more than tripled since 1980, to a rate approaching 1 in 5 (with about 1 in 3 considered overweight or obese).

Case Western Reserve University is addressing this epidemic head-on, having won a $12.5-million grant from the NIH to battle obesity among Cleveland's youth as part of the NIH's Childhood Obesity Prevention and Treatment Research (COPTR) initiative. Toward shutting down youth obesity in Cleveland—where an above-the-national-average 40 percent of children are overweight or obese—the school and its research partners will take steps to increase kids' physical activity, nutritious eating and sleep time, and to improve their stress management skills. The program will give children and their families decision-making tools for their real-world environment, explains Elaine Borawski, PhD, one of the study's principal investigators and a Case Western Reserve University School of Medicine associate professor and co-director of the university's Prevention Research Center for Healthy Neighborhoods. "A child lives within a family, goes to school and resides in a neighborhood," specifies Borawski. "The program is being designed to reduce obesity, while lowering blood pressure, by intervening at all these different levels."

Targeting a Pressing Problem

Obesity is an ominous public health enemy, opening the door to a range of dangerous health conditions. Ohio's obese children are twice as likely to be in poor health compared with their healthy-weight peers, the 2008 Ohio Family Health Survey reveals, with a much greater risk of diabetes, asthma and even mental health problems. And obese children are inviting heart disease and other serious medical problems in their adulthood, as well.

In fact, at a recent public forum in Cleveland on childhood obesity, Ezekiel J. Emanuel, MD, PhD, chair of the bioethics department at the Clinical Center of the NIH, shared a surprising fact about the toll of obesity on mortality. "For the first time in American history, the subsequent generation is actually going to live less long than the current generation—and obesity plays a very large role in that fact."

Yet despite widespread awareness of weight problems among America's children, only about half of obese children receive such a diagnosis by pediatricians, according to research by David Kaelber, MD, PhD, chief medical informatics officer at MetroHealth Medical Center and Case Western Reserve School of Medicine assistant professor of pediatrics and medicine. And when children do receive an obesity diagnosis, many still do not receive the medical attention they need. In another study, Kaelber found that less than a third of children diagnosed as obese were screened for the obesity-related conditions of diabetes and liver and lipid abnormalities. "Many pediatric health care providers are not aware of the current pediatric weight management recommendations," he says. "We need to do a better job educating the public and health care providers about how to diagnose weight problems in children and what to do when a child has a weight problem."

Weight in the Inner City

In Cleveland, as in other urban areas where many families are financially strapped, the risk of obesity is even greater. "There's a very strong correlation between obesity and poverty," Borawski points out. One factor: Cleveland families can lack adequate healthy food options and are often enticed, instead, by less-than-nutritious, convenient alternatives. David E. Harrison, RN, MSN, director of health and social services for the Cleveland Metropolitan School District and a primary partner in this university initiative, sympathizes with residents' plight. "Why is it I can get a candy bar for a dollar but it's two dollars for an apple?" he asks rhetorically. "The cost of fruits and vegetables is outrageous; it's cheaper to eat trans fats and carbohydrates."

And when obesity begins to hit a neighborhood, it can hit it hard. According to Emanuel, obesity has a very worrisome positive feedback loop: Research on social networking has shown that when someone becomes obese, their friends and family have a higher tendency to become obese as well.

Other noted factors that have contributed to skyrocketing obesity rates include an increase in the consumption of soft drinks and fruit drinks. According to Emanuel, over the past 20 years, the average beverage size has gone from 6.5 ounces to 20 ounces. And sugar-sweetened beverages now constitute 11 percent of a child's daily calorie consumption. Overall food portions have gone up as well. Twenty years ago, a bagel had 140 calories; today it packs a whopping 350 calories.

Emanuel also points to media in-take time. The average American kid spends 5.5 hours every day in front of a screen, whether it's the TV, internet or video games. "There's a very strong relationship between [being] overweight and amount of time in front of media," he notes. "A large part of that is inactivity; a large part of that is being exposed to a lot of advertising for food products." Another compounding factor is that food deserts litter the American landscape. "Some families in the United States simply cannot get fresh fruits and vegetables and other healthy things to eat, in large part because supermarkets aren't in inner cities or rural areas," he says.

In Cleveland, according to Borawski, most kids report stopping at a corner store regularly on their way to and from school. And mostly, they're buying soda, chips or candy. As far as the upsurge of sedentary lifestyles, Borawski brings up a valid impediment to behavior change. "People often blame parents for letting their kids sit in front of the TV instead of being active," she says, "but we have to consider that these children may not have a safe place to play."

Against these odds, the new university COPTR program aims to identify the most successful interventions to allow Cleveland's vulnerable children to escape obesity's clutches. "It's a pretty big task," Harrison acknowledges. "Obesity is a systemic problem that must be addressed systemically—considering factors such as economic disparities and community food barriers."

Three Study Tracks to Counter Obesity

The comprehensive NIH-funded study is a seven-year effort being led by Case Western Reserve, in partnership with the Cleveland Metropolitan School District and the YMCA of Greater Cleveland, with clinical expertise provided by University Hospitals (UH) Rainbow Babies & Children's Hospital. The study is co-led by two principal investigators in addition to Borawski: Leona Cuttler, MD, a Case Western Reserve medical school professor of pediatrics and bioethics and director of the Center for Child Health and Policy at UH Rainbow Babies & Children's Hospital; and Shirley M. Moore, RN, PhD, Frances Payne Bolton School of Nursing professor and associate dean for research, and director of the Center for Excellence in Self-Management Research.

Over a two-year period, researchers will recruit about 360 overweight and obese children from some 50 Cleveland schools, through an existing program established by the nursing school in collaboration with Cleveland schools. Those who qualify, based on their body mass index and blood pressure, will be randomized to three groups—each offering a different behavioral intervention for the child and at least one family member, and each offering some degree of phone and face-to-face counseling that varies based on the group. The tracks will assess a variety of tactics, from motivational, problem-solving approaches to redesigning the family environment and daily routines. For instance, families might go grocery shopping with a list when they didn't before, Moore explains, or a child who walks home from school with a friend and habitually stops at a fast food restaurant could mix it up by trying a different route.

The study will also examine the impact of school-based interventions. Half of the participants will come from schools that have an innovative, successful fitness program called We Run This City Youth Marathon Program, where students train for 12 weeks to run or walk a portion of the Cleveland marathon. The study will continue to support this program and introduce nutrition components, a campaign to promote physical activity and "navigators"—health care and physical fitness professionals—to encourage study participants to engage in the opportunities offered. "We're interested to see if a supportive school environment will intensify the impact of family-based interventions," says Borawski.

To help ensure community buy-in and hone the study's design, the team is hosting focus groups with Cleveland's youngsters and their families. "We try out our ideas and get input on improvement," Moore says. "Kids are helping us to better reflect their world by telling us, 'This would be more fun,' and 'that would be really cool.'" A community advisory board will also counsel the study's leaders as the research progresses.

The program leaders hope that lessons learned will help combat obesity not just among kids in the study, says Moore, but among Cleveland's children across the board.