As I’m about to introduce my young daughter to solid foods, I find myself thinking more and more about how I want to avoid using food as a reward—a practice that seems so ingrained in our culture.
There will be no rewards of sweets when my daughter finishes her vegetables or puts her toys away. There will be no lollipops for behaving well during a haircut or any other activity. Yes, I know. More seasoned parents everywhere are reading this and rolling their eyes thinking, “Just you wait.” But is it so crazy to think this isn’t possible? Why can’t rewards be extra outdoor play time or reading another book at bedtime or letting a child pick the family activity for the day, or even an old fashioned gold star sticker?
These same issues seem to follow us into adulthood. In almost every office I’ve worked, treats always seem to magically appear on Fridays as a defacto reward for making it through another week. Or, how about the promises to buy a friend a drink if they help you out with a favor. Instead of rewarding behaviors with food, what about a manicure or downloading of a new phone app. Surely food (or drink) isn’t the only motivator for people.
As NICHQ CEO Charlie Homer points out in his recent blog post about viewing health as a system, if we really want to improve children’s health, we need to focus not just on improving the quality of care children receive when they go to the doctor’s office; we need to change all influences that affect a child’s health. This includes modeling and practicing healthy behaviors at home, in school and in the community.
Are you willing to break the food reward chain with me? Start small. Pick one time this week when you would have traditionally used food as a reward and pick a non-food reward. See how your reward-receivers (your child, your spouse your coworkers) react and share your experience in a comment on this post. I’ll bet nearly 100 percent of people crave the satisfaction of being rewarded in any form, not necessarily by the food that serves as the reward. Once it works, pick another time and another time to swap in non-food rewards.
If enough of us practice this new behavior, as adults with other adults or as adults with children, it won’t seem so odd after a while and we can start to break the chain.
If you’ve read anything about obesity in the lay press over the past week, you already know that there has been a decline in the prevalence of obesity in American preschoolers. The CDC’s latest National Health and Nutrition Examination Survey (NHANES) data, published in the Feb. 26 issue of the Journal of the American Medical Association, show a significant decline in obesity among children aged 2 to 5 years. Obesity prevalence for this age group went from nearly 14 percent in 2003-2004 to just over 8 percent in 2011-2012. This information has been rippling throughout the press this week, with headlines like “U.S. Childhood Obesity Rates Fall 40% in Decade.”
For me, this news is both exhilarating and anxiety provoking. On one hand I have been working throughout that period alongside countless others to achieve a population decrease in body mass index (BMI) and the news that the day may have finally come for one segment of the pediatric population is incredibly encouraging. On the other hand, the rate is still 8.1 percent, as compared to 4.1 percent in the 1971-1974 NHANES cohort, and celebrating too early could distract from the fact that there is so much more work to be done, especially for our most vulnerable children.
The first question that crossed my mind when the news first landed in my inbox is whether the tide has really turned. Experts agree that the sampling methodologies in NHANES are robust and the data are valid. The pressing questions are (a) whether we are really seeing a trend and (b) whether that trend applies to the most vulnerable children.
There are two ways in which I think about data like this. The first is with a gut check—does this jive with what I see in my Community Health Center patients? Although I am not sure that my observation techniques are sensitive enough to see a change from 12 percent in the last cohort to 8 percent in this one, it does seem like recent changes in WIC, SNAP and childcare settings, among others, have made families in my clinic more aware of the impact of healthy eating and active living on the weight and health of their children. And when I saw an obese 2-year-old child this week, I actually thought to myself that I had not seen an obese preschooler in at least a few clinic sessions—certainly a change from five years ago. So is it possible that the tide has turned for preschoolers based on my clinical experience with an underserved urban population? I think so.
But I would be hard pressed to claim that my clinical experience is sufficient to validate public health trends. So I did what improvement junkies do. I went back to the numbers. The most recent data stratified by race and ethnicity has not yet been made available so I was only able to look for a trend among all preschoolers. I plotted the NHANES data from 1999 to 2012 using CDC data to determine if there really is a trend, creating a graph of obesity prevalence over time, what is known in quality improvement as a run chart.
A run chart is designed for the early detection signals of improvement over time through recognition of non-random patterns in the data. The first possible pattern is a “shift,” defined as six or more successive points that are all above or below the median, which in this case is 10.6 percent. If our recent changes in policy and practice had caused a shift beginning in 2005-2006, we would see that the next six points fall below the median. But in fact, the four points from the 2005 cohort to the 2011 cohort alternate between being above and below the median, indicating we don’t have enough data to see a shift and that we don’t appear to be on our way to one just yet. We can also look for a “trend,” defined as five or more consecutive points that are either ascending or descending. Similar to the case of the shift, we neither have enough data points, nor do we have indication that we are on our way to a trend. So despite the change in prevalence, it is challenging to use the data to either establish a new, lower baseline prevalence or to attribute the decrease to the changes we have made to the environments of preschoolers.
So where does that leave me? Trend or no trend, this news means thousands and thousands fewer preschoolers are obese in 2011-2012 vs. 2003-2004 and this fact will have an enormous impact on our health resources and outcomes as they mature. And these data give us hope that sustainable improvement could be just around the corner. In any case, we must continue to invest heavily in activities and policies that promote healthy weight to create a change in prevalence that will persist over time. If nothing else, this is a moment to pause, applaud all of the wonderful changes we have made to date, and energize ourselves for the long road ahead—to the day when we have reversed the trend for ALL Americans, regardless of age, race, or class.
When I first saw McDonald’s Olympic themed advertising that shows Olympians biting their metals contrasted with good looking, fit, young adults biting into chicken nuggets with the tagline, “The greatest victories are celebrated with a bite,” the marketing professional in me thought that was very clever. The parent and healthcare professional in me were horrified.
There are millions of kids watching the Olympics and dreaming of being the next Ted Ligety or Meryl Davis. They are fantasizing about walking into the Olympic stadium for the opening ceremony in a (probably ridiculous looking) red, white and blue outfit. They are picturing themselves standing on the winner’s podium with a shiny metal around their neck and the US national anthem playing in the background. (Even way past my youth in Olympic years, I’m mesmerized by the Olympic spirit and still hold onto the dream of one day being an Olympian regardless of how unrealistic it is.)
But in between watching Gracie Gold on the ice or Bode Miller on the slopes, nearly every commercial break has that McDonald’s bite commercial. How many kids are seeing this commercial and equating McDonald’s chicken nuggets with being an Olympian? McDonalds is an official sponsor after all and there are easily two dozen Olympians featured in the short ad.
Chobani yogurt is also an Olympic sponsor. They’ve been running ads with the tagline, “It’s one thing to sponsor US Olympians. It’s another to be in their fridge.” I wonder how many kids are watching this commercial and see eating Chobani yogurt as a way to be just like hockey player Zach Parise or snowboarder Lindsey Jacobellis, both featured in the commercials.
It’s impossible to control the spin that is put on food advertising. However, as adults who make food purchasing decisions for the children in our lives, we have near complete control in deciding what our children eat and establishing and modeling healthy eating behaviors. It’s not like children can get in the car and drive to McDonalds or the grocery store to get yogurt themselves—even though some days that would be nice.
So, I have a challenge for you. Take 5 to 10 minutes this week, and ask the kids in your life (your own, nieces, nephews, neighbors) about what they think US Olympians eat. Ask them about the McDonald and Chobani ads. Do they think eating these foods will help them become an Olympian? Make note of how you respond and post your findings in the comments below. Let’s get a conversation going about how to talk to children about healthy eating behaviors.
As a school committee member, one of the questions I get asked most often about any holiday we celebrate in schools is “Will you be banning sweets this year?” I’m always surprised by this question because the practice of bringing in sweet treats is itself a longstanding cultural tradition in my school system. In fact, I think there would be people with pitchforks and torches in my yard if we banned this practice.
A friend sent me this article this morning with the provocative title “School Bans Valentine’s Day Candy,” making me revisit this topic. In this case, the principal explained the rationale for the ban to parents like this:
We are working to encourage healthy practices as well as manage food choices in classrooms where food allergies are present in order to maintain a safe environment.
Similarly, other schools across the US have made the choice to limit or ban candy and other indulgent food. The rationale is the same in almost every case: wellness and safety.
At a recent staff gathering at NICHQ I asked the question: Why do we ban things in the name of health? In public health, we use law and regulation to ensure public safety and prevent illness and death. It seems like the right thing to do: ban the things that are bad for people and promote or incentivize the things that are good for health. In particular, schools become targets for these kinds of strategies. But what is the evidence that this actually works?
In our work to prevent childhood obesity, for example, many states have implemented policies to limit or ban sweetened beverages in public schools. The link between sugary drinks and obesity is well-researched. According to the Harvard School of Public Health, children and adults are drinking more sugary drinks than ever before, and there is evidence that both children and adults are better able to control their weight when they reduce their consumption of sugared beverages.
Based on this evidence, it seems like the right thing to do to ban sugary drinks in schools. Unfortunately, the literature presents a mixed bag regarding whether these policies actually reduce student consumption of those drinks overall, and in turn reduces obesity. A 2012 national survey in 40 states by Taber et al. illustrates this point. Taber and his colleagues found that while fifth and eighth grade public school students reduced their access to sugar-sweetened beverages, these children had not reduced their consumption of these drinks. It’s still early in our battle with childhood obesity, and many child advocates are still experimenting with these policies.
If I’ve learned one thing from NICHQ’s work in the obesity space, it is that there is no one magic bullet to prevention and reduction of obesity. It takes multi-sector partnerships including all stakeholders to try to move the big dot toward healthier children. Policies to restrict access to foods linked with increased obesity are only part of an arsenal of tools we have tried to curb obesity. As we continue to experiment using policies limiting or banning access as a means to improve public health, we can benefit from applying quality improvement approaches to test our ideas.
In our community of North Reading, my school committee has never voted to ban candy or any other food item in my history of being on the committee. We prefer to think of policy as something we create in the greater context of student well-being and change, setting the foundation for application of evidence-based practice. Simply banning a food item is a band-aid on a larger problem that deserves a comprehensive approach. We still have a long way to go on the topic of childhood obesity, and we owe it to our children to think outside the cupcake.
What are your thoughts about banning Valentine’s Day candy to improve child health? Please share your thoughts by commenting!
Karen Sautter Errichetti is a two-term elected member of the North Reading School Committee in Massachusetts. The views expressed in this post are those of the author and do not necessarily reflect those of NICHQ.