One of the greatest epidemics threatening the health of our society today is childhood obesity as acknowledged by the World Health Organization (World Health Organization (WHO), 2016). Diseases like childhood obesity are challenging to tackle because there is no simple cause or solution. Complex diseases are often explained by using various multilevel health care models. One such multilevel model of health is the Social Ecological Model (SEM) of health. In this paper I will explain the SEM of health and apply it towards a greater understanding of the childhood obesity epidemic here in Ontario.
The Social Ecological Model is a theory-based framework for understanding the dynamic interrelations among personal and environmental factors that determine behaviours. There are five nested, hierarchical levels of the SEM: individual, interpersonal, community, organizational, and policy, (Unicef, 2014) see Figure 1.
Figure 1 Retrieved from (Sanabria, 2016
This model is frequently used to understand and tackle complex diseases including childhood obesity.
Individual
So why are some children overweight why other children not overweight? It is not as simple as some children are eating more and exercising less. Approximately one in every three children in Ontario is now an unhealthy weight (Healthy Kids Panel, 2013) see Figure 2.
Figure 2 Retrieved from Health Kids Panel (2013)
There has been much research involved in mapping the genes associated with obesity. Due to the complex nature of the disease the goal of this research is to be able to predict which individuals are at high risk early in life and target individual prevention programs before the development of the disease (Choquet & Meyre, 2011).
There has also been research focusing on pregnancy and breastfeeding linked to childhood obesity. Researchers have examined the link between gestational diabetes and weight of the offspring. A systematic review demonstrated a positive association between maternal gestational diabetes mellitus and offspring overweight and obesity (Kim, Sharma, Callaghan, Health, & Commission, 2015). Breastfeeding has been advocated as best for baby for numerous health benefits. Breastfeeding exclusively may provide some protection against overweight and obesity in childhood (Weng et al 2012). Once outside the womb certain individual behaviours such as the amount of sleep can influence weight. Children and adolescents who get less sleep gain more weight (Patel & Hu, 2008). It is challenging to explore the individual attributes and behaviours of children as much of children’s eating and activity levels are determined by their parents in what they choose to feed their children or to engage their children in physical activity. To explore this more we will explore the interpersonal level, particularly the family unit.
Interpersonal
Children are supported by their parents or another adult caregiver to provide the essential of life including shelter, nutrition, and the development of social skills/play/interaction. Children often seek to their parents as role models. It is acknowledged that parents have the greatest influence on children teaching many of their behaviours including eating and exercise habits. An important risk factor for childhood obesity is having parents who are obese. Children with 2 obese parents are 10 to 12 times more likely to be obese (Reilly et al, 2005) (Whitaker et al, 2010). Can this be due to genetics, adopted eating/exercise habits or both? Studies have also examined certain family behaviours such eating together as a family. The proportion of meals that Canadians prepare and eat at home declined from 70 % in 2001 to 65 % in 2008, owing to an increase in dining at restaurants or getting take-out (CRFA, 2010). Since we know that in most cases it is the parent that prepares the meals for young children, we must ask the question, what are we feeding our children? Children are consuming more sugar (especially sugar from drinks) than is required (Gibson, 2008). An excess amount of calories from sugar can lead to weight gain if not used/expended. See Figure 3.
Figure 3 Retrieved from Health Kids Panel (2013
Organizational
Children spend most of their waking hours in the school environment. This organization is designed to best prepare our youth to enter society as productive/heathy/contributing members. It is noted that children spent less time walking to school and are driven by parents either due to lack of time or safety concerns (Active Healthy Kids Canada, 2012). Extracurricular Sporting Organizations also shape youth however only those families that can afford it can only belong to such organizations. (Active Healthy Kids Canada, 2012)
Community
We must acknowledge the larger community we live in and how it has changed over time. The term “obesogenic environment” refers to “an environment that promotes gaining weight and one that is not conducive to weight loss” within the home or workplace (Swinburn, et al., 1999). In today’s fast pace society we know that we are cooking less at home, children are exercising less, consuming more sugar, and spending more time watching tv/or watching devices (Public Health Ontario, 2013).
Certain isolated communities have less access to fresh fruits and vegetables, or simply cannot afford them due to high prices owing to having them imported. Families living in poverty are forced to buy what is affordable as price is the most important factor when buying groceries for many impoverished communities (Healthy Kids Panel, 2013).
There are breakfast and snack programs targeted primarily at low socioeconomic communities such as the Student Nutrition Program SNPs in Toronto that are aimed at ensuring children are provided with a healthy breakfast and snack to optimize their performance in school (Toronto Foundation for Student Success, 2018). While changes can happen at the municipal level it sometimes necessary to enact policies at provincial level to instigate meaningful change
Policy
In 2013 the Ontario Government set a bold, aspirational target: reduce childhood obesity by 20 per cent in five years (Public Health Ontario, 2013). Ontario has implemented many policies targeted at: increasing healthy foods in day care centres and schools, increasing physical activity in schools, and imposing the restaurant industry to change their menus.
For children in daycare there is a policy to ensure that children receive nutritious foods in these settings called the Day Nurseries Act which includes a small subsection on nutrition (Ontario, 1990).
In 2011 the Ontario Government enacted the School Food and Beverage Policy which applies to: food and beverages offered for sale in schools including catered lunch programs, and at all events on school property, including bake sales and sports events (Ontario, 2011).
To tackle a lack of physical activity among youth in 2005 the Ontario government introduced the Daily Physical Activity policy where children from grade 1-8 must receive 20 minutes of physical activity per day. The policy does acknowledge that the recommended daily physical activity for school aged children in 60 however it states that “…before and after school programs, community programs, minor sports and family activities, daily physical activity helps children and youth reach 60 minutes of physical activity per day” (Ontario, 2005) This policy does help place some of the responsibilities on the school system but acknowledges the role of family and community involvement to reach daily targets.
To help Ontarians make healthier choices for themselves and their families while dining out the provincial government instituted the Healthy Menu Choices Act. As of January 1, 2017, all food-service chains with 20 or more locations in Ontario must post the number of calories in the food and drink items they sell. In addition, they must include the following statement “Adults and youth (ages 13 and older) need an average of 2,000 calories a day, and children (ages 4 to 12) need an average of 1,500 calories a day. However, individual needs vary” (Ontario, 2017).
There is much debate about imposing a “sugar tax” on high caloric/low nutrient foods such as pop and candy. While the taxation of high caloric/low nutrient food may deter individuals from purchasing certain food it is thought by many that a sugar tax would harm those members of society that cannot currently afford to afford fresh food and ultimately would harm those already struggling with food costs (Healthy Kids Panel, 2013; World Health Organization (WHO), 2016).
There is also increasing pressure to reduce marketing/advertising to children however this is challenging to tackle at a policy level as there are many International companies (particularly from the United States that broadcast into the Canadian television market (Healthy Kids Panel, 2013).
Looking ahead to the Future
If nothing is done, the current generation of children in Ontario will be the first that has a lower quality of life than their parents. They will develop chronic illnesses much younger and be more affected as they age (World Health Organization (WHO), 2016). As a society, we may lose our hard-fought gains in health. In 2009, obesity cost Ontario $4.5 billion (Katzmarzyk, 2011). We know that obese children are more likely to turn into obese adults (Reilly et al., 2003) which indicates that more action needs to happen now because the cost of obesity will grow, impacting our ability to fund other programs and services.
While this paper is not inclusive of all the factors of childhood obesity it highlights the complexity of this disease through applying the Social Ecological Model of health. We need to act today to have a better future for our children.
References
Active Healthy Kids Canada (2012). Is Active Play Extinct? The Active Healthy Kids Canada 2012 Report Card on Physical Activity for Children and Youth. Toronto: Active Healthy Kids Canada. (Active Healthy Kids Canada, 2012)
Canadian Restaurant and Foodservices Association (CRFA) 2010. Foodservice Facts 2010 Retrieved from https://www.restaurantscanada.org/Results/?q=Food+Service+Facts+2010
Choquet, H., & Meyre, D. (2011). Genetics of Obesity: What have we Learned? Current Genomics, 12(3), 169–179. https://doi.org/10.2174/138920211795677895
Gibson, S. (2008). Sugar-sweetened soft drinks and obesity: A systematic review of the evidence from observational studies and interventions. Nutrition Research Reviews, 21(2), 134–147. https://doi.org/10.1017/S0954422408110976
Government of Ontario. (1990). Day Nursery Act. Retrieved from https://www.ontario.ca/laws/regulation/900262
Government of Ontario. (2011). School Food and Beverage Policy. Retrieved from http://edu.gov.on.ca/eng/healthyschools/policy.html
Government of Ontario. (2005). Daily Physical Activity Policy. Retrieved from http://www.edu.gov.on.ca/eng/healthyschools/dpa.html
Government of Ontario. (2017) Calories on Menus. Retrieved from https://www.ontario.ca/page/calories-menus
Healthy Kids Panel. (2013). No time to wait: the healthy kids strategy. Isbn: 978-1-4606-1014-5sbn: 978-1-4606-1014-5, 63. https://doi.org/017308 ISBN:978-1-4606-1014-5
Kim, S. Y., Sharma, A. J., Callaghan, W. M., Health, P., & Commission, S. (2015). HHS Public Access. Current Opinion Obstetrics and Gynecology, 24(6), 376–381.
https://doi.org/10.1097/GCO.0b013e328359f0f4.Gestational
Public Health Ontario. (2013). Addressing Obesity in Children and Youth: Evidence to Guide Action for Ontario. https://doi.org/ISBN 978-1-4606-0812-8 [PDF]
Reilly, J., Methven, E., McDowell, Z., Hacking, B., Alexander, D., Stewart, L., & Kelnar, C. (2003). Health consequences of obesity. Archives of Disease in Childhood, 88(9), 748–752. https://doi.org/10.1136/adc.88.9.748
Swinburn B, Egger, G, Raza F. (1999) Dissecting obesogenic environments: the development and application of a framework for identifying and prioritizing environmental intervention for obesity. Preventative Medicine (6 pt 1) 563-70.
Toronto Foundation for Student Success. (2018) Retrieved from https://tfss.ca/student-nutrition-programs/
Unicef (2014) What is the Social Ecological Model. Retrieved from https://www.unicef.org/cbsc/files/Module_1_SEM-C4D.docx
World Health Organization (WHO). (2016). Report of the Commission on Ending Childhood Obesity. World Health Organization, 30. https://doi.org/ISBN 978 92 4 151006 6
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