Biological and genetic factors

A biological model assists in identifying children who are overweight or obese. If identified early, these children can receive personalized early interventions (pharmacologic, lifestyle, and diet measures) or preventive health care that decreases their vulnerability to chronic health disorders (e.g., diabetes, orthopedic abnormalities, and cardiovascular disease).⁵³

Recent research studies, especially genome-based ones, have identified family susceptibility to obesity. Children and adolescents who are genetically predisposed to obesity will gain weight when exposed to a suboptimal diet-and-exercise pattern (e.g., poor diet and lack of exercise). Research identifying chromosomes related to weight is relatively new, and the findings are mostly provisional. Further evidence of heritable factors and the scope of knowledge of biological factors related to excessive weight gain will become more comprehensive with time.

Early-onset obesity is a symptom that occurs in some chromosomal syndromes, including the Mendelian syndromes Prader Willi syndrome, Albright hereditary osteodystrophy, and Bardet Biedel syndrome.³¹ Associated characteristics with weight gain in these syndromes are small stature, low activity levels, low muscle tone (hypotonia), and intellectual disability. In other chromosomal disorders, weight gain is a secondary problem. For example, children with Down syndrome often are overweight or obese due to low intensity of activity and other physical factors such as low muscle tone, heart defects (restricting participation in and endurance for physical activity), and hypothyroidism.⁶⁰

Since hormonal, metabolic, and neuronal factors regulate weight, the body seeks to maintain a baseline weight, and the desire for food is adjusted accordingly through a feedback system involving the interaction of peripheral hormones, gastrointestinal peptides, and neuropeptides.³¹ OT practitioners need to be aware of the biological and genetic factors that may be contributing to a child’s weight. For example, hypothyroidism slows metabolic rate, and children with this disorder will need to perform high-intensity activities.

Physical factors: activity and dietary behaviors

Diet, sedentary behaviors, and lack of physical activity are modifiable causal factors of childhood and adolescent obesity. For example, insufficient physical activity is a recognized risk factor for obesity and related chronic conditions, whereas engaging in physical activity from an early age (toddlers) protects children from excessive weight gain.^28,53 These physical activity patterns established in childhood positively influence later activity patterns. Unfortunately, for many, especially girls, participation in physical activity declines across childhood and into adolescence.⁴⁸ The Centers for Disease Control (CDC) Youth Media Campaign Longitudinal Study found that 61.5% of children between the ages of 9 to13 years did not participate in any organized physical activity in nonschool hours, and 22.3% did not participate in any free time activity.¹³

Low physical activity and sedentary behaviors are interrelated. However, healthy children and adolescents have a balance of low and high physical activities and derive benefits developmentally from both. For example, a child may be an avid reader, play sports, go hiking with his family, and watch TV and maintain a healthy weight. The growth in technology-based leisure pursuits such as watching TV, playing video games, and engaging in multiple forms of computer-mediated communication have contributed to sedentary behaviors and the resultant rise in obesity.¹ The problem is not that sedentary activities require a low expenditure of energy. Rather, sedentary activities may displace high-physical-energy activities, and children who engage in sedentary activities end up with a lower metabolic rate than their physically active peers do.

Numerous personal and environmental factors also lead to a predominantly sedentary activity pattern. For example, poverty contributes to higher levels of sedentary activities and poor diet. Similarly, some sedentary activities promote higher food intake and/or unhealthy eating patterns. For example, TV advertisements promote fast foods, snacks, and drinks that appeal to children, but these foods are often high in sugar and fats. Eating while watching TV encourages snacking, whereas sitting down at the table for a family meal models healthy eating patterns and helps children monitor food intake and portion size. Furthermore, family meals are associated with a higher intake of vegetables and a lower intake of such items as sodas and fried foods.²³

Diet and eating behaviors are central to obesity; children and adolescents who are physically active are more likely to have a healthy diet.⁴⁹ Genetic, demographic, family, sociocultural, and physical factors collectively influence the foods children experience, have access to, and the patterns around food intake that they learn (Box 14-3). Eating patterns, in relation to diet and food preferences, in households where a parent is obese differ from households in which neither parent is obese.^2,48 Dysfunctional habits and routines contribute to low activity and poor diet patterns among children, adolescents, and their families.

Behavioral dietary and physical activity interventions have been shown to effectively address weight issues and the psychosocial problems associated with obesity.⁵⁴ However, interventions for children who have parents with their own challenges around diet and weight are less successful, and therefore interventions need to be family centered.⁴⁹

Environmental factors: social, economic, cultural, and physical

Family and peer relationships, attitudes, education, ethnicity, and behaviors, school/community environments and societal attitudes are the socioeconomic, cultural, and physical factors that influence activity patterns, eating behaviors, and attitudes toward food, physical activity, leisure choices, and personal weight (e.g., body image). Therefore, they can contribute positively or negatively to a child and adolescent’s weight.⁴⁹ For example, environmental factors may support and encourage a healthy active lifestyle, but they can equally be barriers to positive behavioral change. A 2-year study of households that restricted certain foods, especially when it involved the mother’s dietary restriction, found that the weights of the children in these households increased.¹⁷ An explanation for this finding may be that when these children managed to get access to the restricted foods, they ate more of them. In contrast, the availability of healthy foods (e.g., fruits and vegetables) in the home and the healthy eating patterns modeled by parents (and grandparents) positively influence food preferences and eating behaviors that will persist when children begin to make their own choices about the foods they will eat.²⁰

Since the family environment has a significant effect on eating and exercise patterns, it is important to establish healthy eating and exercise habits early, since parental control over children’s diet lessens during adolescence.²¹ Adolescents are more likely to purchase foods outside the home, and these foods are often foods of convenience, which are high in sugars and fats and of questionable nutritional value. This change in diet can lead to weight gain. Peers and the media also become influential forces of behaviors and attitudes concerning weight, body image, and choices about how discretionary time is spent.

Physical environment and social trends influence activity levels and choice of activities as well. Increasingly, parents have become concerned about their children’s safety, especially in urban settings. Outcomes of this trend are that children are less likely to walk or cycle to school, and less of the free time is spent playing in parks, since parents prefer to supervise their children in public spaces. Some concern has arisen that these changes are leading to less creative and less vigorous physical play.⁶ At the same time, intense marketing of sedentary computer-mediated games and a decline in the availability of sports and physical education for a range of abilities continue to occur. Additionally, sport activities increasingly exclude disadvantaged children because of the cost of equipment, the lack of resources in communities, and both parents needing to work and being unable to take their children to sport activities. Fewer and fewer students at the elementary and high school levels are participating in any form of organized physical activity.⁵² The national “Let’s Move” initiative and many state initiatives are seeking to reverse this trend by increasing child and family activity levels and providing education to improve children’s nutrition.

Stigma, discrimination, and social exclusion

Body size is the most stigmatizing physical characteristic after race. In a study examining perceptions about disabilities, OT students ranked obesity as one of the hardest disabilities to live with.¹¹ Adults, adolescents, and children who are obese are viewed as unattractive in comparison with the Western ideal of physical attractiveness that is based on thinness.^10,33 Furthermore, obesity is associated with stereotypical characteristics such as laziness, self-indulgence, unreliability, untrustworthiness, and lack of self-discipline.^8,46,56 Children as young as 3 years old have been found to stereotype children who are obese as “ugly,” “stupid,” and “dirty.”²⁴ These negative attitudes are also prevalent among adults working in the field of education. One fifth of high school teachers and health care workers stated that they thought obese persons were more emotional, less tidy, less likely to succeed at work, and had personalities different from those of people who are not obese.²⁴

Children or adolescents who are overweight or obese are susceptible to teasing, discrimination, and social exclusion.⁵⁹ Forty-five percent of children with weight issues reported being teased, compared with 15% of children with normal weights.²⁴ Weight-related teasing and poor body image have been shown to be significant issues among elementary school children who are obese.²⁵ Besides the painful experiences of being teased or bullied, they also experience psychological, attitudinal, and behavioral negative outcomes. For example, children who experience weight-related criticism are likely to have negative attitudes toward sports and engage less in physical activities.¹⁹ Some studies found that adolescents who reported weight-related teasing were more likely to have dysfunctional patterns of weight control such as smoking, purging, using laxatives and diuretics, and fasting than did their peers without weight-related problems. Because of the high incidence of weight-related teasing and antifat prejudicial attitudes, practitioners should assume that children who are overweight have been victimized (e.g., bullied) and are sensitive to any comments about weight.

Occupational therapy practitioners’ attitudes toward obesity

OT practitioners themselves are not free of the stereotypical attitudes associated with obesity.⁵⁷ Research has found that the prejudicial antifat attitudes prevalent in society are consistent with the attitudes of many health care professionals.^22,57 In a recent study, OT students were more likely to negatively evaluate and show discriminatory attitudes toward clients who were obese than toward clients who were not obese. The study showed that OT students are less likely to choose to work with clients who are obese, to view them as deserving of sympathy and understanding, and to find it easy to be empathetic toward them.⁵⁷

Despite the ethical guidelines of the OT profession, which unequivocally states that all people are entitled to equal and compassionate care, antifat attitudes negatively influence OT practitioners’ relationships with children and adolescents who are overweight. All OT practitioners need to examine their attitudes and their stereotypical beliefs concerning obesity and how these attitudes and beliefs influence their approaches to interventions for children and adolescents who are obese.