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Winter 2009

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Probing childhood obesity Illustration: Glynis Sweeny

When bigger isn't necessarily better

UB researchers probe the complex causes of childhood obesity, developing treatments that are pioneering and family focused

By Susan M. LoTempio

That childhood obesity has reached epidemic proportions in America is a troubling, yet not particularly new, fact. What’s far more complex and worrisome, however, is the question: what can be done about it?

“The problem is real,” says Suzanne Laychock, professor and senior associate dean for research and biomedical education in the UB School of Medicine and Biomedical Sciences. “Obesity has become one of the most major health problems in the world.”

The numbers are startling. The Journal of the American Medical Association reports that 16.3 percent of American children ages 2 to 19 are obese; an additional 15.6 percent are considered overweight. If that’s not sufficiently disturbing, a 2005 study found that today’s children in the United States could be the first generation in modern times to have shorter lives than their parents because of obesity-related health issues.

In general terms, according to the Centers for Disease Control and Prevention, “overweight” and “obesity” “are both labels for ranges of weight that are greater than what is generally considered healthy for a given height. The terms also identify ranges of weight that have been shown to increase the likelihood of certain diseases and other health problems.”

According to Laychock, “no one really understands what’s driving obesity [in both children and adults]—it is a multifactorial problem.” Are the causes overeating, genetics, learned behavior, the endocrine system, too much stress or a combination of some or all of these factors? UB researchers are working to unravel this complicated question.

And with a body of work that spans 20 years and a team that includes both medical doctors and scientists with PhDs, “UB researchers have had an impact on the issue,” Laychock says.

Sarah-Jeanne Salvy, assistant professor of pediatrics, Division of Behavioral Medicine, agrees. “It will take a while to tackle all the factors involved in this epidemic—there is some work to do at the level of the individual and their close system [family, peers, friends], and also in terms of public health policies. However, I have no doubt that some of these solutions will originate from the research of my colleagues,” Salvy says.

“Our work continues to develop on multiple levels,” explains Leonard H. Epstein, chief, Division of Behavioral Medicine, Department of Pediatrics in the UB School of Medicine and Biomedical Sciences.

James N. Roemmich (left) and Leonard H. Epstein James N. Roemmich (left) and Leonard H. Epstein are part of a UB team examining ties between high park access and children’s physical activity. Photo: Eric Frick

“We are very interested in genetics of food reinforcement and obesity; the role of different behavioral, dietary and activity approaches to treatment; and how habits develop. Our work attempts to translate the newest basic science into effective clinical interventions,” adds Epstein, who has been involved in childhood obesity research for 30 years, 15 years at UB.

In the 1970s, Epstein developed the Traffic Light Diet, which is used in his current research and also by health-care professionals around the country. The diet links food to the three colors of a traffic light: red indicates high-calorie foods that should be eaten rarely, yellow denotes moderate-calorie foods that can be eaten occasionally and green is for low-calorie foods that can be consumed freely.

It’s that practical approach that is central to the work being done by UB researchers as they dig deeply into the habits of young people with weight issues.

Role of the family

A recent UB study showed that by using a device that restricts video viewing time on TVs and computers, parents could cut the time spent on video games an average of 17.5 hours a week. Also, the children’s body mass index (BMI) was significantly lower by the end of the two-year study. (BMI is a calculation of one’s weight to height.)

“Results show that watching television and playing computer games can lead to obesity by reducing the time that children are physically active, or by increasing the amount of food they consume as they engaged in these sedentary behaviors,” Epstein reports.

“Our treatments take a family approach, and show strong relationships between child and parent behavior and weight change. When we compare child and parent weight change, our data suggest that it is easier for children to lose [weight] and maintain weight loss than their parents, as they have not had the unhealthy behaviors as long as their parents,” Epstein explains.

“Parents are extremely powerful role models for the eating and exercise habits of their children—not only ‘what’ and ‘how much’ they eat, but also their relationship to physical appearance, food, physical activity and overall health,” says Salvy. “Parents can set the occasions for physically active activities with peers/friends and family members.”

Still, there are roadblocks when trying to motivate youth with weight issues to be more physically active.

“The increase in obesity is likely due, in part, to changes to our home and neighborhood environments that have influenced access to and choices to be active or sedentary,” says James N. Roemmich, associate professor of pediatrics and exercise and nutrition sciences. “I have become especially interested in how the environment—such as the physical layout of neighborhoods—affects children’s weight-control choices.”

As principal investigator in a number of studies (and collaborating with Epstein, along with Samina Raja and Li Yin of the School of Architecture and Planning faculty), Roemmich found that “children and adolescents who lived in neighborhoods that provided greater access to parks were more physically active.”

However, “that research didn’t answer whether children were actually using the parks to be physically active,” Roemmich points out.

Further research showed that “adolescents most frequently used their home lot, their friend’s lots, parks and vacant lots to get their physical activity.” Roemmich and his team also are studying how park design—such as the choice of play equipment within parks—motivates children to be physically active.

Adds Roemmich: “We are now studying whether reducing access to television and computer time by 50 percent within the home encourages overweight adolescents to go outside and be physically active, and whether those who have access to neighborhood parks find it easier to increase their physical activity.”

At UB’s Childhood Weight Control Program, which Epstein heads, one research study combines healthier eating behavior, innovative ways to increase activity and behavior modification to help overweight children between the ages of 8 and 12, and who have at least one overweight parent, to lose weight and then maintain a normal weight.

Breaking the cycle

In an especially innovative study, Teresa Quattrin, UB professor of pediatrics and a specialist in childhood endocrinology and diabetes, is testing the effectiveness of a treatment to be carried out at the pediatrician’s office in collaboration with the family and the child’s doctor. The aim is to break the cycle of obesity in families.

Since children of overweight parents are at risk to become overweight early in life, and overweight children are at risk of becoming obese adults, Quattrin has shifted her focus to younger children. In Western New York, she says, three out of 10 young children are close to being overweight or are already overweight.

“In the summer of 2002, realizing that the number of overweight children without additional hormonal disorders was increasing alarmingly, I decided to analyze the data pertinent to the children referred by Western New York pediatricians [to the endocrinology clinic at the Women and Children’s Hospital of Buffalo] over the previous 10 years,” says Quattrin, chief of service for pediatrics for Kaleida Health. Serving also as interim chair of the Department of Pediatrics, she points out that the current project “would not be possible without the critical mass of scientists from the Department of Pediatrics, who are invaluable collaborators.

“These data, among several things, illustrated that there was a delay between the time the child was becoming overweight and the referral [by the pediatrician],” Quattrin continues. “Growth data provided by the pediatrician in about 251 children showed that more than 80 percent of children who had been referred to our endocrinology clinic had in fact become overweight before school age.

“This was the point in my career when I decided that our focus had to shift from adolescence to early childhood. Also, it became clear that we needed to involve the family, and this was an ideal situation in a young child who is still totally dependent on his/her parents.”

Working with practices in the Buffalo area that are affiliated with Women and Children’s Hospital—Amherst Pediatrics, Suburban Pediatrics and Hodge Pediatrics—the researchers are investigating whether the program can promote weight maintenance or modest weight loss in children ages 2 to 5 while the children grow in height, and whether the child will see a decreased percentage BMI over time.

Baby fat not 'cute'

Changing eating and activity patterns also are a part of the study. The preschool-age children will be taught good eating habits before they have to “unlearn” bad ones. Parents will learn that a young child who is rapidly gaining weight is at risk for obesity, and that the problem needs to be addressed—and not ignored or dismissed because of cultural perceptions that “baby fat is cute.”

“In this pioneer translational project, pediatricians are playing a key role on the team,” Quattrin explains. “They identify young children when they are at risk for [becoming] overweight, or are overweight, and counsel the family that this is the time they can benefit from the program. “In cases when the child is at risk for [becoming] overweight, maintaining the weight will gradually make the child well-proportioned. [But] if the child is already overweight, weight loss is necessary while the child grows in height.”

Another approach to the childhood obesity problem explored at UB is how the environment can influence food selection, food intake and activity choices (physical or sedentary) in both children and adolescents. “More specifically, I am interested in the effects of social influence on eating and activities in overweight and non-overweight youth,” Salvy explains.

“We’ve been conducting several studies assessing how peer relationships, or the lack thereof, impact youth’s eating and physical activity. These studies indicate that overweight youth (but not lean youth) eat more when alone than when in the presence of peers, and are also less physically active when alone than when in company of other youth,” Salvy says.

“In fact, we showed that the presence of peer and friends can increase the value of physical activity in overweight youth. In other words, overweight youth are more likely to engage in physically active leisure activities when they have the opportunity to do the activities with peers and friends.”

According to Salvy, UB researchers want to better understand “how social isolation resulting from teasing and weight criticism may decrease the motivation to be physically active and involved with peers, and increase the time spent eating and doing sedentary activities.”

She adds: “We are now starting a new series of studies on the effect of peer rejection versus peer acceptance on eating in overweight and non-overweight youth. We are also interested in examining overweight youth’s emotional responses to social conflicts.”

Although it’s impossible to mention every UB research study on childhood obesity conducted over 20 years, there is one other current study that deserves particular note. This is Roemmich’s work on “how psychological stress influences weight status.”

“We have shown that children who have greater increases in heart rate and blood pressure when giving a speech about themselves, increases their eating of comfort food and reduces their willingness to be physically active,” Roemmich explains. “They would rather watch television when stressed. From these results you would expect that children who are the most stress-reactive are more overweight, and we have shown this association.”

The child obesity research at UB is funded by the National Institutes of Health, a grant from the Foundation for Healthy Living (Blue Cross/Blue Shield) and a Robert Wood Johnson Foundation grant, among other funding sources.

Looking back on his years of research, Epstein says that he and his treatment team often hear what happened to some children once a treatment study is over.

“We get feedback from parents about children becoming more social and having more friends; becoming active and joining and starring on athletic teams,” Epstein states.

“I am most pleased with the fact that we had an impact on the quality of life of these children and their families.”

Susan M. LoTempio has been an editor at the Buffalo News for 22 years.

Global airing for UB obesity research

News outlets from all over the world reported on the study conducted at UB by Leonard H. Epstein, chief, Division of Behavioral Medicine, Department of Pediatrics in the UB School of Medicine and Biomedical Sciences. It revealed that watching TV and playing computer games can lead to obesity in children by reducing the amount of time they are physically active.

The results of the study appeared in the March 2008 issue of the Archives of Pediatric & Adolescent Medicine, and were picked up by U.S. news outlets, including USA Today, the New York Times, New York Daily News, Fox News, Denver Post, National Public Radio, Bloomberg News, Reuters, Washington Post, Chicago Tribune, Pittsburgh Post-Gazette, U.S. News & World Report, Seattle Post Intelligencer and United Press International.

The research also gained international attention through media reports in India, Canada, England, Australia, Scotland, Sri Lanka, Thailand, New Zealand, Malaysia and Estonia.