Childhood obesity in Hawai'i: the role of the healthcare provider.

Childhood obesity in Hawai‘i is a signifi cant problem; in some of our rural and low-income communities more than 40% of children entering kindergarten are overweight or obese.1 Studies in this issue of the Hawai‘i Medical Journal Supplement highlight other concerns related to the development of obesity in childhood. The current problems refl ect the complex and rapid changes in our society over the last 30 to 40 years and our underlying biologic susceptibilities.2 Think about your own childhood, what you ate, how you ate and played and the differences of your experiences from those of your children and grandchildren. For families living in poverty, or near poverty as many in Hawai‘i do, the changes have been most dramatic and the solutions less apparent. Individual behaviors including eating behaviors, food choice, and physical activity are shaped by the powerful infl uences of society and the environment;3 today these include television, video games, work schedules, child-care realities, transportation barriers, and educational challenges. Unhealthy behaviors become embedded by social expectations and less obvious issues such as food insecurity, housing, employment barriers, and racism — issues that have likely worsened in this recent recession.4 The discussion around childhood obesity often involves personal and parental responsibility and choices in nutrition and physical activity. Focus on the individual is what we in health care have been trained to do; it is what we are comfortable doing. It has also been the prime focus socially and politically. Such a view takes responsibility away from government and industry. But focusing only on the individual ignores the fact that we now live in world where the default and easiest choice is to remain sedentary and to eat large amounts of fat fi lled, sweetened foods. Caloric beverages are now the single greatest source of added sugar in the American diet.5 Portion sizes have ballooned. Salt, sugar, and fat content have skyrocketed. Hawai‘i’s cultural traditions that embrace food as an offering of gratitude, graciousness and love have evolved to support this. The food incentives throughout a child’s day include the Krispy Crème donut omiyage and the 1000 calorie “snack” bags after every soccer and baseball game starting from age fi ve. Studies have identifi ed factors in the modern food environment that disable the body’s physiologic and psychological regulatory systems that are supposed to govern the delicate balance between hunger, satiety, and weight. 6 These obesity generating forces have made it incredibly diffi cult to be “responsible” especially for those struggling with poverty and other modern stressors in life. Health education is important. Kids and parents must become interested in behavior change and healthy lifestyles and have some knowledge and understanding on how to take those steps. Families must understand that disease can be prevented without feeling blamed. Education must be culturally sensitive and locally relevant. But of course we know that health education alone will not create behavior change. Healthy behavior change cannot and will not happen in a vacuum. What is the role of the pediatrician and other heath professionals in the problem? Some fear that we will do more harm by talking about obesity. Some say that there is no proof that spending our time talking about weight and growth does anything. Is obesity really a high priority in the face of other health disparities? School failure, drug use, homelessness, mental health and behavioral concerns, and developmental concerns are all top priorities in childhood. These issues are all important. While many physicians may doubt their infl uence, studies have shown that families trust and listen to their doctors.7,8 I’ve pondered these questions at length and have informally asked parents and kupuna their thoughts. The overwhelming majority have been in favor of pediatricians talking about growth, chronic disease risk and nutrition. As one grandmother said, “If my doctor doesn’t talk to us about these issues with us, who will?” But if we are to bring about change and prevent childhood obesity and related diseases, we must support our families and begin addressing the issue at all levels — from the individual to the systems and policies that shape the environment. Healthier choices must become the default choice for children and families. Healthcare providers must become part of this collective change. As in the tobacco movement, health professionals must take on a dual approach, addressing both the individuals and the complex environment with a comprehensive array of medical and community interventions including community-wide campaigns, school-based interventions, mass media strategies, and action to bring about legal and regulatory changes.9 The passage of a tax on sweetened beverages in Hawai‘i is one such measure.