Budding Bariatrics

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GUEST EDITORIAL

Budding Bariatrics

Sherrill A. Conroy

Jack Sprat could eat no fat by age 72; 77% of obese children aged 7-13 years His wife could eat no lean remain obese as adults.3 Suboptimal fetal and Success resembles a fat cat infant growth and overnutrition and under- Obesity starts before they wean nutrition may further contribute to risk of chronic diseases such as obesity, type 2 diabetes, coronary heart disease, stroke, and high blood hildhood obesity is increasing at an alarm- pressure or hypertension. High-birth-weight ba- Cing rate in Canada. The number of over- bies (> 4000 g) are often born to mothers who weight and obese children jumped from 9-11% are diagnosed with gestational diabetes or are at in 1986 to 33% in 1996 for boys aged 7-13 years risk for developing type 2 diabetes. The greatest and from 13% to 27% for girls aged 7-13 years.1 variation in rates of weight gain in early infancy But when does obesity actually start for these is when infants may show signiﬁcant “catch- children? Our childhood obesity prevention re- up” or “catch down” growth. Because early obe- search team at the Faculty of Nursing of the sity is a predictor for adolescent or adult obesity, University of Alberta wanted to know what is there are tremendous implications for early recognized about causes of obesogenesis during prevention of childhood obesity, including nu- pregnancy and infancy and its prevention. The trition and safety issues and other bariatric study discovered not only solid pathophysio- concerns, such as wound healing. We must do logical determinants of childhood obesity but something to stem this trend toward obesity, also a culture of obesity that is burgeoning in starting right at the beginning of life. this country. Why is this happening today? So- Childhood obesity has multiple causes that ciety promotes an acceptability of obesity within include a genetic predisposition and lifestyle certain sectors. In many ethnic groups found in habits, such as minimal physical activity and Canada, people’s success is measured by the size poor dietary habits during pregnancy, and in of their girth; overweight babies are perceived childhood. Given the escalating costs of health- as healthy. How can we stop this trend? When care, the increase in childhood obesity in our should we start? Given there are so many bio- society will place a bigger burden on an already socio-economic factors to consider, where do overextended healthcare system. In addition, we start? It took Katherine Moore to understand these children who are obese will experience a the connection between my research interest in reduced quality of life as they age. early childhood obesity prevention and WOCN Already, millions of dollars have been ex- when she kindly invited me to write the guest pended to present healthy lifestyle and nutri- editorial for this special bariatric issue. It is clear tional models to the public. We know that later that obesity is comorbid with multiple bariatric conditions that have their beginnings in childhood and are related to how we eat, what we eat, Sherrill A. Conroy, PhD, RN, Assistant Professor, and how we burn off the calories. These activi- University of Alberta, Faculty of Nursing, Edmonton, ties are learned at our mothers’ knees. Alberta, Canada. Correspondence: Sherrill A. Conroy, PhD, RN, Assistant Rapid weight gain by low-birth-weight babies Professor, Faculty of Nursing, University of Alberta, (< 2500 g) in the ﬁrst 4 months of life is associ- 3rd Floor Clinical Sciences Building, Edmonton, Alberta, ated with an increased risk of being overweight T6G 2G3 Canada (e-mail: [email protected]).

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childhood-onset and adult-onset chronic cardiovascular dis- deemed healthy by healthcare professionals. This gap must eases and diabetes are not limited to those in poor financial be bridged by the professionals.6 The American Academy conditions. The majority of people who are obese, however, of Pediatrics, however, has focused primarily on treatment are found in low socioeconomic settings4 where they lack recommendations and not on combined medical, psycho- effective coping skills and financial resources to adapt their logical, and emotional evaluation or barriers to care.7 life style toward what has healthier health outcomes. A large The gap must be better understood to determine how portion lives on social assistance that is barely adequate for intervention programs can be effectively delivered. One of subsistence living. Mothers need to have a fixed address be- the barriers to obesity prevention is a lack of practical pre- fore they can access a social assistance check. It is appalling, vention skills and public health training as regular parts of therefore, that welfare systems ensure that families have medical education. A multidisciplinary health team ap- access to television sets before providing coupons to ensure proach to obesity prevention program initiatives is re- healthy eating and active recreation activities. quired to address childhood obesity, particularly in the Our challenge is to at least address the following fac- prenatal and early infancy time periods. Little is known tors at individual, community, and policy levels to effect about why parents choose to pay attention or to ignore the desirable changes in lifestyle: advice of healthcare clinicians in the areas of obesity prevention, particularly in the younger age group. Low socioeconomic status (LSES) gives rise to social New approaches are needed to understand the differ- conditions in which access to foods and adequate ent perceptions that are held by clients and healthcare activity are constrained by low income and lower professionals. We need to know more about why families education of mothers (in particular). seek treatment or where to direct our clinical practice when High stress persists for LSES populations when try- diagnosing and treating childhood obesity. We need to ing to make ends meet amid limited social support work with mothers as active partners if interventions are conditions. to succeed. It is clear that we need to start preventing obe- Pregnancy and childbirth occur within a family sogenesis from an early age if we are to stem the trend to- setting. When resources are scarce, pregnant wo- ward obesity and its comorbid conditions. We cannot men often forego feeding themselves if doing so afford to wait to take action until the children have stopped means that their older children will have adequate learning nursery rhymes! food, while inadvertently starving the latest family addition. Urban and risky lifestyles combined with a LSES fos- ■ ter low activity levels, especially within a culture References where the only entertainment may be perceived to 1. Tremblay MS, Katzmarzyk PT, Willms JD. Temporal trends in be a television set. Walking is eschewed in favor of overweight and obesity in Canada, 1981-1996. Int J Obes. 2002; taking a bus to travel short distances. 26:538-543. 2. Stettler N, Zemel BS, Kumanyika S, Stallings VA. Infant weight Cultural perceptions about the meaning of fatness or gain and childhood overweight status in a multicenter, cohort thinness are passed down through the generations5 and to study. Pediatrics. 2002;109:194-199. 3. Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. new immigrants. Social interactions and support systems, Relationship of childhood obesity to coronary heart disease communities, and economic standing level combine with risk factors in adulthood: the Bogalusa Heart Study. Pediatrics. underlying pathophysiology to affect the obesity epidemic 2001;108:712-718. in multiple ways. How a person reacts to life stressors af- 4. Canadian Institute of Health Information. Improving the Health fects his or her health and outlook on life. Stress and risky of Canadians. Ottawa: Canadian Institute of Health Information; 2004. lifestyle behaviors can contribute to illness directly or in- 5. Frisancho AR. Reduced rate of fat oxidation: a metabolic path- directly. People living with LSES are constantly living way to obesity in the developing nations. Am J Hum Biol. 2003; under the stress of making ends meet. 15:522-532. Most LSES mothers have views about the definition, 6. Jain A, Sherman SN, Chamberlin LA, Carter Y, Powers SW, cause, and management of obesity that differ greatly from Whitaker RC. Why don’t low-income mothers worry about their preschoolers being overweight? Pediatrics. 2001;107:1138-1146. those of most healthcare professionals. This perception 7. Price JH, Desmond SM, Ruppert ES, Stelzer CM. Pediatricians’ gap is even greater between what LSES mothers consider perceptions and practices regarding childhood obesity. Am J a healthy weight for their children compared with that Prev Med. 1989;5:95-103.