*Social Work Health Care*. Vol.49, No.6, pp.565-580, ISSN 0098-1389.

No.4, (Feb 2009), pp.708-716, ISSN 0277-9536.

No.12, (Dec., 2006), pp.2266-2276, ISSN 1930-7381.

No.9, (Sep., 2008), pp.682-695, ISSN 1047-2797.

Vol.57, No.3, pp.292-299, ISSN 0735-1097.

2003), pp.1448-1453, ISSN 0009-7322.

7166.

0276-3478.

(Feb, 2009), pp.133-139.

transition to adulthood: a factor analysis approach. *Social Science & Medicine*. Vol.68,

race/ethnicity and life course socioeconomic status across the transition from adolescence to adulthood. *Journal of Epidemiology & Community Health*. Vol.63, No.2,

the national longitudinal survey of youth, 1997. *Obesity (Silver Spring)*. Vol.14,

and behavioral determinants of childhood and adolescent obesity in the United States: Analyzing independent and joint associations. *Annals of Epidemiology. Vol.*18,

mortality, and cardiovascular events: Population-based study with ongoing mortality and hospital events follow-up. *Journal of the American College of Cardiology*.

risk in children: an American Heart Association Scientific Statement from the Atherosclerosis, Hypertension, and Obesity in the Young Committee (Council on Cardiovascular Disease in the Young) and the Diabetes Committee (Council on Nutrition, Physical Activity, and Metabolism). *Circulation*. Vol.107, No.10, (Mar.,

*International Journal of Pediatric Obesity, Vol.*1,No 1.,(Jan., 2006), pp.11-25, ISSN 1747-

between body mass index and television viewing, Internet use and cellular phone use: The moderating effects of socio-demographic characteristic and exercise. *International Journal of Eating Disorders*. Vol.43, No.6, (Sep., 2010), pp.565-571, ISSN Obesity is a complex problem with no simple solutions. In the quest to find possible solutions for this growing problem among children, literature has already indicated a gap between evidence-based research and practice-based intervention (Robert Wood Johnson Foundation, 2008). This chapter will provide a focus on childhood obesity in South Africa, and will discuss the extent of this problem within the complex context of the South African demographics. It often happens that when researchers have published the results of intervention studies or clinical trials, they may walk away totally satisfied with positive and promising results. The challenge however, remains to translate these research results for practitioners to be used as "tools" in addressing the existing problem. This chapter, therefore, intends to deal with practice-based solutions and recommendations suggesting some strategies in this part of the world.

In order to understand the problem of childhood obesity better in the context of this country (South Africa) it is important to shortly review the socio-economic conditions that currently prevail in this part of the continent as demographic background information.

### **2. Demographic background**

Human growth and development do not take place in a biological vacuum, but in an environmental context where several factors, including genetic potential can affect the development of the child (Cameron, 2005). It is also proved that many so called "developing countries" around the world, of which South Africa is one, at present, are undergoing epidemiological transition (Goedecke et al., 2006). This process is associated with some typical health risks, not only for the adult population, but also for children (Cameron, 2005). Although South Africa is a country with high potential, and many efforts are made to improve the health and well-being of the people living here, many challenges exist to the health and optimal development of children growing up in this country. This country with 50 million people is described as a developing and middle-income country with high socioeconomic disparities (46.3% low socio-economic, 53.7% in middle to high socio-economic) (Zere & McIntyre, 2003), where more than 14 million people were beneficiaries of income support in 2010 and 24.8% were living below the food poverty line in 2008 (Millenium Development Goals, Country Report, 2010). Statistics show that 40% (18.3 million) of the South African population are 18 years and younger. African children accounted for 84% of

Childhood Obesity: The Need for Practice Based Solutions – A South African Perspective 195

Furthermore recent data in the USA, where the national obesity rates have tripled among children and adolescents over the last 30 years**,** suggest that obesity is now responsible for more disability and activity limitations than smoking. As a direct result of this obesity epidemic, doctors are noticing a significant rise in chronic illnesses among children. Obese children are also more than twice as likely to develop type 2 diabetes than children of normal weight (CDPH, 2010). In California, cost attributable to physical inactivity, obesity and overweight in 2006 was estimated at \$41.2 billion. This suggests, however, that a 5% improvement in each risk factor could result in annual savings of nearly \$2.4 billion (CDPH, 2010). This burden is also indicated in many other countries around the world, viz: Australia and UK. In South Africa it is estimated that 30% of ischaemic heart disease, 27% of colon cancer, 22% of ischaemic stroke and 20% of type 2 diabetes were attributable to physical inactivity (Joubert et al., 2007). Thus, considering the major burden/health concern of obesity in child and adulthood as well as the complex co-morbidities originated from obesity, it is imperative that more focus should be directed on the developing child to reinforce healthy lifestyles in order to reduce the burden of non-communicable diseases of

Kruger et al. (2005) indicated that obesity prevention initiatives should be focused on children to ensure the adoption of a healthy lifestyle from an early age. The challenge to deal with this epidemic should, therefore, rather be to prevent it, highlighting childhood as a critical developmental phase. It is agreed that besides genetic predisposition, lifestyle habits are determined in the first years of a child's life. During this critical phase of human development some developmental "windows of opportunity" occur (Gabbard 1998). When optimal stimulation is not received during these critical periods, the opportunity passes, leaving the individual in many cases with some developmental restrictions. Intervention later in life can improve the situation but the individual may never reach his/her optimal potential in the specific area. The words of the previous Surgeon General of the USA, Dr. Everette Koop, sum up this situation viz. (1996*): "Everything we have ever done in health education, as good as it might be, always has one fault: It's too late.*", again emphasizing that the

A worldwide increase in childhood obesity is reported, including in South Africa. Kruger et al. (2005) reported in this regard that earlier South African studies (1996-1998) showed a prevalence of about 10% of overweight and obesity among children in this country. More recent statistics indicate higher incidences that are similar to that of developing countries a decade ago (Steyn et al., 2005; Armstrong et al., 2006). Differences are also reported between urban and rural environments, indicating that urbanisation plays a role in the prevalence of

The results of a nationally representative study ("National Food Health Consumption Survey" (Labadarios, 1999) of 1-9 year old children indicated that 6.7% of them were overweight and 3.7% were obese. When international BMI standards as proposed by Cole et al. (2000) were applied to these results, 17.1% of the children were classified as overweight and obese (Steyn et al., 2005). Another comprehensive study among 6 and 13 year old children and also based on the same cut-off values indicates a prevalence of 14% and 3.2% of overweight and obesity among boys, while 17.9% and 4.9% of girls were overweight and obese respectively (Armstrong et al., 2006). Statistics in a regional representative sample of

obesity, while ethnic and gender differences are also evident from reported statistics.

period of childhood is a critical phase on which to focus.

**4. Prevalence of childhood obesity in South Africa**

adulthood.

the total child population, while white (5%) coloured (9%) and Indian (2%) children comprise the rest (South African Child Gauge, 2008/2009). In 2007, two thirds of these children lived in income poverty and about 40% in a household where no adult is employed.

Another health burden is HIV, the epidemic that affects health, livelihoods, economic growth, demographic futures, as well as impacting on the lives of individuals, families and workplaces (Millenium Development Goals, Country Report, 2010). HIV and AIDS have had a significant negative impact on life expectancy in South Africa, and have left many families and children economically vulnerable and often socially stigmatized and continue to leave South Africa with a legacy of young adult deaths. AIDS orphans are socially and economically vulnerable children (South African Child Gauge, 2008/2009). The adult incidence of HIV and AIDS for sub-Saharan Africa was 5.2% compared to a global total incidence of 0.8% in 2008. The proportion of HIV positive babies in 2009-2010 was 9.4% and statistics further show that the HIV prevalence among pregnant women aged 15– 24 years is 22.8%, with an overall national transmission rate of 11% of HIV to babies born to HIVinfected mothers. HIV is also associated with other life threatening conditions, with tuberculoses being the most common opportunistic infection, with rates exceeding 70% (Millenium Development Goals, 2010)**.** All of the above contribute to South Africa having a high <5 years child mortality rate that is reported to be still much higher than the set target for South Africa by 2015. It is, therefore, not strange that the main priorities of this country are to alleviate poverty and improve primary health care among children in an effort to decrease early childhood mortality.

### **3. Obesity – A health burden**

Recent statistics obtained by the National Health and Nutrition Examination Survey in the USA indicate 21.5% overweight and 10.4% obesity among 2-5 year olds (Ogden et al., 2010a), while increasing tendencies are also reported in this age group in Europe and Australia (Baur, 2001; Maffeis et al., 2006; Apfelbacher, 2008; Cretikos et al., 2008). Even bigger increases are reported in developing countries such as Thailand (WHO, 2010) and Chili (Kain et al., 2002). Although this disease is not life threatening during the childhood years, and mainly the result of lifestyle related habits, it is prevalent among affluent and less affluent families and has lifelong consequences with an increasing burden on the healthcare system of a country as the child grows older. This growing epidemic of childhood obesity can, therefore, not be ignored in the health care focus of any country. The Medical Research Council of South Africa (Steyn, 2007) reported that health services spend 8 billion rand per annum involving direct and indirect costs resulting from lifestyle related diseases such as heart disease and stroke (Steyn, 2007). Pienaar (2009) argues that disease prevention is as important as the treatment thereof and should receive high priority in the country. This researcher recommends that strategies should be put in place to prevent diseases from a very young age as research indicates that exposure to health risks due to physical inactivity, which is one of the main causes of childhood obesity, already start in childhood, although the consequences or clinical symptoms may only occur in mid- to later life when the individual reaches the clinical horizon (Rowland, 1990). Kruger et al. (2005) also highlight that obesity needs to be viewed as a disease in its own right and one that warrants intervention even when comorbidities are not present.

the total child population, while white (5%) coloured (9%) and Indian (2%) children comprise the rest (South African Child Gauge, 2008/2009). In 2007, two thirds of these children lived in income poverty and about 40% in a household where no adult is

Another health burden is HIV, the epidemic that affects health, livelihoods, economic growth, demographic futures, as well as impacting on the lives of individuals, families and workplaces (Millenium Development Goals, Country Report, 2010). HIV and AIDS have had a significant negative impact on life expectancy in South Africa, and have left many families and children economically vulnerable and often socially stigmatized and continue to leave South Africa with a legacy of young adult deaths. AIDS orphans are socially and economically vulnerable children (South African Child Gauge, 2008/2009). The adult incidence of HIV and AIDS for sub-Saharan Africa was 5.2% compared to a global total incidence of 0.8% in 2008. The proportion of HIV positive babies in 2009-2010 was 9.4% and statistics further show that the HIV prevalence among pregnant women aged 15– 24 years is 22.8%, with an overall national transmission rate of 11% of HIV to babies born to HIVinfected mothers. HIV is also associated with other life threatening conditions, with tuberculoses being the most common opportunistic infection, with rates exceeding 70% (Millenium Development Goals, 2010)**.** All of the above contribute to South Africa having a high <5 years child mortality rate that is reported to be still much higher than the set target for South Africa by 2015. It is, therefore, not strange that the main priorities of this country are to alleviate poverty and improve primary health care among children in an effort to

Recent statistics obtained by the National Health and Nutrition Examination Survey in the USA indicate 21.5% overweight and 10.4% obesity among 2-5 year olds (Ogden et al., 2010a), while increasing tendencies are also reported in this age group in Europe and Australia (Baur, 2001; Maffeis et al., 2006; Apfelbacher, 2008; Cretikos et al., 2008). Even bigger increases are reported in developing countries such as Thailand (WHO, 2010) and Chili (Kain et al., 2002). Although this disease is not life threatening during the childhood years, and mainly the result of lifestyle related habits, it is prevalent among affluent and less affluent families and has lifelong consequences with an increasing burden on the healthcare system of a country as the child grows older. This growing epidemic of childhood obesity can, therefore, not be ignored in the health care focus of any country. The Medical Research Council of South Africa (Steyn, 2007) reported that health services spend 8 billion rand per annum involving direct and indirect costs resulting from lifestyle related diseases such as heart disease and stroke (Steyn, 2007). Pienaar (2009) argues that disease prevention is as important as the treatment thereof and should receive high priority in the country. This researcher recommends that strategies should be put in place to prevent diseases from a very young age as research indicates that exposure to health risks due to physical inactivity, which is one of the main causes of childhood obesity, already start in childhood, although the consequences or clinical symptoms may only occur in mid- to later life when the individual reaches the clinical horizon (Rowland, 1990). Kruger et al. (2005) also highlight that obesity needs to be viewed as a disease in its own right and one that warrants intervention even when co-

employed.

decrease early childhood mortality.

**3. Obesity – A health burden**

morbidities are not present.

Furthermore recent data in the USA, where the national obesity rates have tripled among children and adolescents over the last 30 years**,** suggest that obesity is now responsible for more disability and activity limitations than smoking. As a direct result of this obesity epidemic, doctors are noticing a significant rise in chronic illnesses among children. Obese children are also more than twice as likely to develop type 2 diabetes than children of normal weight (CDPH, 2010). In California, cost attributable to physical inactivity, obesity and overweight in 2006 was estimated at \$41.2 billion. This suggests, however, that a 5% improvement in each risk factor could result in annual savings of nearly \$2.4 billion (CDPH, 2010). This burden is also indicated in many other countries around the world, viz: Australia and UK. In South Africa it is estimated that 30% of ischaemic heart disease, 27% of colon cancer, 22% of ischaemic stroke and 20% of type 2 diabetes were attributable to physical inactivity (Joubert et al., 2007). Thus, considering the major burden/health concern of obesity in child and adulthood as well as the complex co-morbidities originated from obesity, it is imperative that more focus should be directed on the developing child to reinforce healthy lifestyles in order to reduce the burden of non-communicable diseases of adulthood.

Kruger et al. (2005) indicated that obesity prevention initiatives should be focused on children to ensure the adoption of a healthy lifestyle from an early age. The challenge to deal with this epidemic should, therefore, rather be to prevent it, highlighting childhood as a critical developmental phase. It is agreed that besides genetic predisposition, lifestyle habits are determined in the first years of a child's life. During this critical phase of human development some developmental "windows of opportunity" occur (Gabbard 1998). When optimal stimulation is not received during these critical periods, the opportunity passes, leaving the individual in many cases with some developmental restrictions. Intervention later in life can improve the situation but the individual may never reach his/her optimal potential in the specific area. The words of the previous Surgeon General of the USA, Dr. Everette Koop, sum up this situation viz. (1996*): "Everything we have ever done in health education, as good as it might be, always has one fault: It's too late.*", again emphasizing that the period of childhood is a critical phase on which to focus.

### **4. Prevalence of childhood obesity in South Africa**

A worldwide increase in childhood obesity is reported, including in South Africa. Kruger et al. (2005) reported in this regard that earlier South African studies (1996-1998) showed a prevalence of about 10% of overweight and obesity among children in this country. More recent statistics indicate higher incidences that are similar to that of developing countries a decade ago (Steyn et al., 2005; Armstrong et al., 2006). Differences are also reported between urban and rural environments, indicating that urbanisation plays a role in the prevalence of obesity, while ethnic and gender differences are also evident from reported statistics.

The results of a nationally representative study ("National Food Health Consumption Survey" (Labadarios, 1999) of 1-9 year old children indicated that 6.7% of them were overweight and 3.7% were obese. When international BMI standards as proposed by Cole et al. (2000) were applied to these results, 17.1% of the children were classified as overweight and obese (Steyn et al., 2005). Another comprehensive study among 6 and 13 year old children and also based on the same cut-off values indicates a prevalence of 14% and 3.2% of overweight and obesity among boys, while 17.9% and 4.9% of girls were overweight and obese respectively (Armstrong et al., 2006). Statistics in a regional representative sample of

Childhood Obesity: The Need for Practice Based Solutions – A South African Perspective 197

therefore, not limited to a specific ethnic, age or socio-economic group, indicating that cultural, environment and genetic factors should also be taken into consideration when causes of childhood obesity are analysed. Further some of the major factors that may be

Obesity in the general population is much more likely to result from excess calories consumption and sedentary lifestyle than from any other factors (Kimm, 2004). Most commonly, obesity (overnutrition) leads to an accelerated growth rate and tall stature during childhood with early achievement of normal adult height. Poverty and unemployment on the other hand, generally result in poor levels of nutrition, increased levels of food insecurity and incidences of malnutrition (Millenium Development Goals, 2010)**.** A reasonable proxy for income poverty and hunger is child under-nutrition. It is reported that 2.7 million children live in households that reported child hunger (South African Child Gauge, 2008/2009). The underweight-for-age incidence rate (a weight less than 60% of estimated 'normal' weight-for-age) is generally higher than the severe malnutrition incidence rates of a country. Severe malnutrition is reported to average over the period 2001 to 2010 to be between 4.4% and 13.3% for the <5 year old in the different provinces of South Africa (District Health Information System in the Department of Health). These poor levels of nutrition contribute to growth deficiencies such as stunting (retarded growth) and wasting (low weight-for- age). In this regard the Barker hypotheses implicates the fetal in-utero environment as a significant determinant of risk for major chronic diseases such as cardiovascular disease, hypertension, type 2 diabetes and obesity, later in life (Kimm, 2004). In a study done on a Fillipino group of children, low birth weight was associated with higher blood pressure and heavier bodyweight during adolescence (Kimm, 2004). Small stature associated with obesity during child and adulthood can, however, result from a diverse set of conditions (Kimm, 2004). These include being born small for gestational age, postnatal malnutrition, hormone abnormalities such as deficiencies of growth hormone or thyroid hormone, late effects after childhood, cancer, certain medications, and genetic syndromes. Common features of growth disorders in the context of obesity include limited growth hormone or thyroid hormone or their action, or limited sensitivity to insulin. Abnormalities of leptin and newly identified appetite-regulating peptides may also lead to poor growth and overweight. Popkin et al. (1996) were the first to highlight that the prevalence of childhood obesity was greater in children who were stunted in communities undergoing nutritional transition. In this regard Naude et al. (2008) reported higher BMI, fat percentages and intra-abdominal fat storage among stunted children compared to non-stunted children in South Africa. From the previous discussion it is obvious that children born under these difficult conditions suffer a high risk of stunting during infancy, and that growth retardation during early childhood is associated with significant dysfunctional improvement during adulthood (Cameron, 2005) including obesity (Popkin et al., 1996). This phenomenon was also supported by a study of Ravelli et al. (1976) on the importance of adequate nutrition during the prenatal period in children born under famine conditions. The most famous of these was the "Dutch Hunger Winter" beginning in October 1944 when food suppliers to the Dutch cities were reduced due to German occupation of the Western Netherlands (Cameron, 2005). During this time the average per capita daily ratio of approximately 1800 kcal/day dropped to 600kcal/day**.** In the follow-up

relevant in this regard will be outlined briefly.

**5.1 Poverty**

7-year old children in one of the nine provinces of South Africa, the North West Province, indicates an overweight and obesity prevalence of 11.64 % (overweight =7.84%; obesity =3.80%) (Kemp et al., 2011), with significant differences between gender and children growing up in different socio-economic environments. The prevalence of obesity is reported to vary between rural and non-rural communities (Monyeki et al., 1999) with higher percentages reported in the non-rural areas. Monyeki et al. (1999) reported the prevalence of overweight in 3 to 10 year old children in disadvantaged communities in the Limpopo Province as low (0% - 2.5% and 0% - 4.3% among boys and girls respectively) while Steyn et al. (2005) reported the highest prevalence of overweight (20.1%) in urban areas and the lowest in farming communities.

Studies on overweight and obesity among boys and girls show a gradual increase as girls get older, with significant differences between genders. Statistics on 10-12 year old girls living in the North West Province of SA, indicating 16.52% to be overweight and 4.93% to be obese (Pienaar et al., 2007). The "International Obesity Task Force" reported that 25% of all SA girls in the 13-19 year age group are overweight, compared to 7% of boys (Somers et al., 2006). Somers et al. (2006) further indicated that overweight among 10-16 year old girls (21.1%) was significantly higher than among boys (8.4%), with no significant differences with regard to obesity. A possible explanation is that girls are more prone to overweight and obesity, especially before the onset of the growth spurt at about 10-years of age and after menarche has commenced (Armstrong et al., 2006).

Differences are also reported between ethnic groups and those living in different socioeconomic conditions (McVeigh et al., 2004 & Armstrong et al., 2006). These researchers reported that White boys and girls showed the highest BMI values, although after the age of 11 years, black girls presented with the highest BMI values. The incidence of overweight and obesity among Black girls increased from 12% at the age of 6-years to 22% at the age of 13-years, while a decreasing trend from 25% to 15% was found among White girls. The "South African Youth Risk Behaviour" study reported the incidence of overweight and obesity among Black, White and Indian girls in the 13-19 year old group as 30%, 34% en 41% respectively (Steyn, 2005). Pienaar et al. (2007) found ethnical differences in a representative sample of 10-12 year old girls living in the North West Province of South Africa, where White girls showed the highest percentage of overweight (21.28%), followed by Indian (17.39%), Black (15.81%) and Coloured girls (9.10%). Indian girls showed the highest prevalence of obesity (8.7%) followed by White (8.51%) and Black girls (4.35%), with no obesity found among coloured girls in this age group. Somers et al. (2006) investigated the prevalence of overweight and obesity among 10-16 year old children in rural environments in the Western Cape Province of South Africa, and found that 15.7% of the children were overweight and 6.2% obese. The prevalence of overweight was also much higher among Black children (21.8%) than Coloured children (13.7%), with similar trend regarding obesity in the two ethnic groups (5.8% versus 6%). Black girls showed the highest percentage (30.8%) of overweight especially in the 16-year old children.

### **5. Causes of childhood obesity in South Africa**

The problem of childhood obesity is very complex in this country due to some historical, socio-economic and other circumstances. Kruger et al. (2005) suggested that various socioeconomic and cultural factors may contribute to the obesity epidemic in South Africa. It is, therefore, not limited to a specific ethnic, age or socio-economic group, indicating that cultural, environment and genetic factors should also be taken into consideration when causes of childhood obesity are analysed. Further some of the major factors that may be relevant in this regard will be outlined briefly.

### **5.1 Poverty**

196 Childhood Obesity

7-year old children in one of the nine provinces of South Africa, the North West Province, indicates an overweight and obesity prevalence of 11.64 % (overweight =7.84%; obesity =3.80%) (Kemp et al., 2011), with significant differences between gender and children growing up in different socio-economic environments. The prevalence of obesity is reported to vary between rural and non-rural communities (Monyeki et al., 1999) with higher percentages reported in the non-rural areas. Monyeki et al. (1999) reported the prevalence of overweight in 3 to 10 year old children in disadvantaged communities in the Limpopo Province as low (0% - 2.5% and 0% - 4.3% among boys and girls respectively) while Steyn et al. (2005) reported the highest prevalence of overweight (20.1%) in urban areas and the

Studies on overweight and obesity among boys and girls show a gradual increase as girls get older, with significant differences between genders. Statistics on 10-12 year old girls living in the North West Province of SA, indicating 16.52% to be overweight and 4.93% to be obese (Pienaar et al., 2007). The "International Obesity Task Force" reported that 25% of all SA girls in the 13-19 year age group are overweight, compared to 7% of boys (Somers et al., 2006). Somers et al. (2006) further indicated that overweight among 10-16 year old girls (21.1%) was significantly higher than among boys (8.4%), with no significant differences with regard to obesity. A possible explanation is that girls are more prone to overweight and obesity, especially before the onset of the growth spurt at about 10-years of age and after

Differences are also reported between ethnic groups and those living in different socioeconomic conditions (McVeigh et al., 2004 & Armstrong et al., 2006). These researchers reported that White boys and girls showed the highest BMI values, although after the age of 11 years, black girls presented with the highest BMI values. The incidence of overweight and obesity among Black girls increased from 12% at the age of 6-years to 22% at the age of 13-years, while a decreasing trend from 25% to 15% was found among White girls. The "South African Youth Risk Behaviour" study reported the incidence of overweight and obesity among Black, White and Indian girls in the 13-19 year old group as 30%, 34% en 41% respectively (Steyn, 2005). Pienaar et al. (2007) found ethnical differences in a representative sample of 10-12 year old girls living in the North West Province of South Africa, where White girls showed the highest percentage of overweight (21.28%), followed by Indian (17.39%), Black (15.81%) and Coloured girls (9.10%). Indian girls showed the highest prevalence of obesity (8.7%) followed by White (8.51%) and Black girls (4.35%), with no obesity found among coloured girls in this age group. Somers et al. (2006) investigated the prevalence of overweight and obesity among 10-16 year old children in rural environments in the Western Cape Province of South Africa, and found that 15.7% of the children were overweight and 6.2% obese. The prevalence of overweight was also much higher among Black children (21.8%) than Coloured children (13.7%), with similar trend regarding obesity in the two ethnic groups (5.8% versus 6%). Black girls showed the highest percentage (30.8%) of overweight especially in the 16-year old

The problem of childhood obesity is very complex in this country due to some historical, socio-economic and other circumstances. Kruger et al. (2005) suggested that various socioeconomic and cultural factors may contribute to the obesity epidemic in South Africa. It is,

lowest in farming communities.

children.

menarche has commenced (Armstrong et al., 2006).

**5. Causes of childhood obesity in South Africa**

Obesity in the general population is much more likely to result from excess calories consumption and sedentary lifestyle than from any other factors (Kimm, 2004). Most commonly, obesity (overnutrition) leads to an accelerated growth rate and tall stature during childhood with early achievement of normal adult height. Poverty and unemployment on the other hand, generally result in poor levels of nutrition, increased levels of food insecurity and incidences of malnutrition (Millenium Development Goals, 2010)**.** A reasonable proxy for income poverty and hunger is child under-nutrition. It is reported that 2.7 million children live in households that reported child hunger (South African Child Gauge, 2008/2009). The underweight-for-age incidence rate (a weight less than 60% of estimated 'normal' weight-for-age) is generally higher than the severe malnutrition incidence rates of a country. Severe malnutrition is reported to average over the period 2001 to 2010 to be between 4.4% and 13.3% for the <5 year old in the different provinces of South Africa (District Health Information System in the Department of Health). These poor levels of nutrition contribute to growth deficiencies such as stunting (retarded growth) and wasting (low weight-for- age). In this regard the Barker hypotheses implicates the fetal in-utero environment as a significant determinant of risk for major chronic diseases such as cardiovascular disease, hypertension, type 2 diabetes and obesity, later in life (Kimm, 2004). In a study done on a Fillipino group of children, low birth weight was associated with higher blood pressure and heavier bodyweight during adolescence (Kimm, 2004). Small stature associated with obesity during child and adulthood can, however, result from a diverse set of conditions (Kimm, 2004). These include being born small for gestational age, postnatal malnutrition, hormone abnormalities such as deficiencies of growth hormone or thyroid hormone, late effects after childhood, cancer, certain medications, and genetic syndromes. Common features of growth disorders in the context of obesity include limited growth hormone or thyroid hormone or their action, or limited sensitivity to insulin. Abnormalities of leptin and newly identified appetite-regulating peptides may also lead to poor growth and overweight. Popkin et al. (1996) were the first to highlight that the prevalence of childhood obesity was greater in children who were stunted in communities undergoing nutritional transition. In this regard Naude et al. (2008) reported higher BMI, fat percentages and intra-abdominal fat storage among stunted children compared to non-stunted children in South Africa. From the previous discussion it is obvious that children born under these difficult conditions suffer a high risk of stunting during infancy, and that growth retardation during early childhood is associated with significant dysfunctional improvement during adulthood (Cameron, 2005) including obesity (Popkin et al., 1996). This phenomenon was also supported by a study of Ravelli et al. (1976) on the importance of adequate nutrition during the prenatal period in children born under famine conditions. The most famous of these was the "Dutch Hunger Winter" beginning in October 1944 when food suppliers to the Dutch cities were reduced due to German occupation of the Western Netherlands (Cameron, 2005). During this time the average per capita daily ratio of approximately 1800 kcal/day dropped to 600kcal/day**.** In the follow-up

Childhood Obesity: The Need for Practice Based Solutions – A South African Perspective 199

socio-economic circumstances, 53.7% are brought up in middle to high socio-economic conditions (Zere & McIntyre, 2003). Children growing up in such households are more likely to participate in passive pastimes such as TV watching and computer games. Television viewing of more than 3 hours per day and the absence of Physical Education in SA schools are reported to contribute to more sedentary behaviour and obesity among school going children (Medical Research Council, 2002). In addition, Van der Merwe (2004) indicated that 40% of all advertisement during TV programmes for children, is about food products with a high fat and or suger content, which encourage a higher energy intake. Trends have also changed where in most households, both parents are working and children have to stay at daycare centres or in after-school programmes, which restrict them to participate in after school activity programmes (Pienaar, 2009). High crime rates, unsafe environments and stranger fear is a reality in South Africa with a profound effect on children moving freely and unrestricted around and playing outside (Bourne et al., 2002; Sabin et al., 2004). This contributes to parents being afraid of using public transport which

In South Africa 17% of primary school children and 29% of secondary school children have to travel more than 30 minutes to reach the school nearest to them. Many children in low socio-economic situations have to walk to school by necessity, and benefit from this activty, but this is associated with hardship and when such children have an option later in their life, they will choose easier options to commute, contributing to a more sedentary lifestyle (Lennox et al., 2007). Very high percentages of TV watching (especially watching soap operas) is also reported among adolescents living in poor socio-economic circumstances, especially girls. This behaviour provides an easy escape from their daily reality, but contributes to sedentary lifestyles (Lennox et al., 2007). This trend is similar in America which indicates the highest percentages of obesity among children living in poor socio-

Studies indicate that parental overweight and obesity are the biggest risk factor for overweight and obesity among children (Van der Merwe, 2004). The "American Academy of Child and Adolescent Psychiatry" indicates that when both parents are obese, the risk for the child to be also obese is 80%, and 50% when one parent is obese (AACAP, 2010). This relationship is also reported to be higher with the mother (Padez et al., 2005). The cultural perception of overweight and obesity as acceptable, make this factor an important

This part will focus on a summary of research findings regarding the success of different intervention strategies and the knowledge that practitioners can gain from these results in order to treat childhood obesity more effectively. Successful strategies, barriers and

Before commencing with this discussion it is, however, important to provide a conceptualization of the health paradigms. In order to understand the roles of various health disciplines in illness, health and well-being, and to understand how the treatment of childhood obesity and the manifestations of this condition fits into the illness/well-being

challenges will be further identified in the treatment process of childhood obesity.

decreases walking and bicycling activities among children.

economic conditions (Ogden et al., 2010b).

contributing factor to overweight in this country.

**6. Evidence-based practice to intervention-based practice**

**5.5 Familial obesity**

study of Ravelli et al. (1976) it was indicated that in men (Dutch military conscripts) exposed to famine in the first two trimesters of pregnancy, the prevalence of obesity was dramatically increased compared to those exposed to famine in the third trimester or postnatally. A possible mechanism underpinning this phenomenon is not yet well established but may be linked to the so-called "intra-uterine programming" (Cameron, 2005). Following birth this programming caused them to respond adversely to changes in lifestyle that may result in obesity in later life (Cameron, 2005).

Other indicators of overweight and obesity are mothers that smoke and the absence of breastfeeding (Burke, 2006). To minimize mother-to-baby transmission of the HIV virus, breastfeeding practices are not recommended among HIV positive mothers. A link was also confirmed between low educational level and a higher BMI in a group of economically active South Africans representing four different ethnic groups in the country (Senekal et al., 2003).

### **5.2 Urbanisation and diet**

Kruger et al. (2005) reported that the obesity epidemic in South Africa reflects globalization which is the primary driving mechanism towards nutritional transition. These researchers indicated that more freedom of movement of especially the black population and an increase in exposure to the global market economy led to a shift from traditional foods, low in fat and rich in fibre, towards meat and diary products containing high levels of saturated fats and more highly refined foods. Globalization may, therefore, increase the risk amongst the urban population by creating an evironment which is conducive to the consumption of food rich in fat and sugar (Bourne et al., 2002; MacIntyre et al., 2002). Urbanisation is also linked to a higher income which contributes to a higher fat intake and an increase in sedentary behaviour (Kain et al., 2004; Van der Merwe, 2004). It is further indicated that in townships and among street vendors, cheap fatty meat and snacks and few fruit and vegatables are sold (Kruger et al., 2005).

### **5.3 Cultural differences**

The diverse culture of the 4 major ethnic groups in South Africa (Asian, black, coloured and whites/Caucasian) contributes to deepen the complexity of the problem. Kruger et al. (2005) indicate that culture shapes eating habits. In some cultures social gatherings encourage overeating and certain foods (luxurious foods rich in fat and energy) are associated with social status and become more acceptable among urban South Africans. In some of the groups, overweight (and obesity) reflects the "good" life viz, wealth, good standing, attractiveness and absence of HIV/AIDS, which is associated with respect, dignity and affluence, therefore, a bigger body size is more acceptable (Senekal et al., 2001; Puoane & Hughes, 2005). In this scenario a paradigm shift is necessary to convince individuals about the health consequences of obesity and overweight.

### **5.4 Sedentary behaviour and physical inactivity**

Sedentary behaviour is identified as one of the most important contributing factors of childhood obesity (Steyn, 2005). Dodd (2007) reported that the increased prevalence among children can mainly be attributed to a decrease in energy expenditure and increased sedentary behaviour. Although South Africa has high percentages of children living in poor socio-economic circumstances, 53.7% are brought up in middle to high socio-economic conditions (Zere & McIntyre, 2003). Children growing up in such households are more likely to participate in passive pastimes such as TV watching and computer games. Television viewing of more than 3 hours per day and the absence of Physical Education in SA schools are reported to contribute to more sedentary behaviour and obesity among school going children (Medical Research Council, 2002). In addition, Van der Merwe (2004) indicated that 40% of all advertisement during TV programmes for children, is about food products with a high fat and or suger content, which encourage a higher energy intake. Trends have also changed where in most households, both parents are working and children have to stay at daycare centres or in after-school programmes, which restrict them to participate in after school activity programmes (Pienaar, 2009). High crime rates, unsafe environments and stranger fear is a reality in South Africa with a profound effect on children moving freely and unrestricted around and playing outside (Bourne et al., 2002; Sabin et al., 2004). This contributes to parents being afraid of using public transport which decreases walking and bicycling activities among children.

In South Africa 17% of primary school children and 29% of secondary school children have to travel more than 30 minutes to reach the school nearest to them. Many children in low socio-economic situations have to walk to school by necessity, and benefit from this activty, but this is associated with hardship and when such children have an option later in their life, they will choose easier options to commute, contributing to a more sedentary lifestyle (Lennox et al., 2007). Very high percentages of TV watching (especially watching soap operas) is also reported among adolescents living in poor socio-economic circumstances, especially girls. This behaviour provides an easy escape from their daily reality, but contributes to sedentary lifestyles (Lennox et al., 2007). This trend is similar in America which indicates the highest percentages of obesity among children living in poor socioeconomic conditions (Ogden et al., 2010b).

### **5.5 Familial obesity**

198 Childhood Obesity

study of Ravelli et al. (1976) it was indicated that in men (Dutch military conscripts) exposed to famine in the first two trimesters of pregnancy, the prevalence of obesity was dramatically increased compared to those exposed to famine in the third trimester or postnatally. A possible mechanism underpinning this phenomenon is not yet well established but may be linked to the so-called "intra-uterine programming" (Cameron, 2005). Following birth this programming caused them to respond adversely to changes in lifestyle that may

Other indicators of overweight and obesity are mothers that smoke and the absence of breastfeeding (Burke, 2006). To minimize mother-to-baby transmission of the HIV virus, breastfeeding practices are not recommended among HIV positive mothers. A link was also confirmed between low educational level and a higher BMI in a group of economically active South Africans representing four different ethnic groups in the country (Senekal et al.,

Kruger et al. (2005) reported that the obesity epidemic in South Africa reflects globalization which is the primary driving mechanism towards nutritional transition. These researchers indicated that more freedom of movement of especially the black population and an increase in exposure to the global market economy led to a shift from traditional foods, low in fat and rich in fibre, towards meat and diary products containing high levels of saturated fats and more highly refined foods. Globalization may, therefore, increase the risk amongst the urban population by creating an evironment which is conducive to the consumption of food rich in fat and sugar (Bourne et al., 2002; MacIntyre et al., 2002). Urbanisation is also linked to a higher income which contributes to a higher fat intake and an increase in sedentary behaviour (Kain et al., 2004; Van der Merwe, 2004). It is further indicated that in townships and among street vendors, cheap fatty meat and snacks and few fruit and

The diverse culture of the 4 major ethnic groups in South Africa (Asian, black, coloured and whites/Caucasian) contributes to deepen the complexity of the problem. Kruger et al. (2005) indicate that culture shapes eating habits. In some cultures social gatherings encourage overeating and certain foods (luxurious foods rich in fat and energy) are associated with social status and become more acceptable among urban South Africans. In some of the groups, overweight (and obesity) reflects the "good" life viz, wealth, good standing, attractiveness and absence of HIV/AIDS, which is associated with respect, dignity and affluence, therefore, a bigger body size is more acceptable (Senekal et al., 2001; Puoane & Hughes, 2005). In this scenario a paradigm shift is necessary to convince individuals about

Sedentary behaviour is identified as one of the most important contributing factors of childhood obesity (Steyn, 2005). Dodd (2007) reported that the increased prevalence among children can mainly be attributed to a decrease in energy expenditure and increased sedentary behaviour. Although South Africa has high percentages of children living in poor

result in obesity in later life (Cameron, 2005).

2003).

**5.2 Urbanisation and diet**

vegatables are sold (Kruger et al., 2005).

the health consequences of obesity and overweight.

**5.4 Sedentary behaviour and physical inactivity**

**5.3 Cultural differences**

Studies indicate that parental overweight and obesity are the biggest risk factor for overweight and obesity among children (Van der Merwe, 2004). The "American Academy of Child and Adolescent Psychiatry" indicates that when both parents are obese, the risk for the child to be also obese is 80%, and 50% when one parent is obese (AACAP, 2010). This relationship is also reported to be higher with the mother (Padez et al., 2005). The cultural perception of overweight and obesity as acceptable, make this factor an important contributing factor to overweight in this country.

### **6. Evidence-based practice to intervention-based practice**

This part will focus on a summary of research findings regarding the success of different intervention strategies and the knowledge that practitioners can gain from these results in order to treat childhood obesity more effectively. Successful strategies, barriers and challenges will be further identified in the treatment process of childhood obesity.

Before commencing with this discussion it is, however, important to provide a conceptualization of the health paradigms. In order to understand the roles of various health disciplines in illness, health and well-being, and to understand how the treatment of childhood obesity and the manifestations of this condition fits into the illness/well-being

Childhood Obesity: The Need for Practice Based Solutions – A South African Perspective 201

Fig. 2. The role of kinderkinetics in the various health paradigms (Adapted from Strydom et

In Fig. 2, the three constructs regarding health, viz, *illness care, illness prevention* and *health promotion* are arranged into the two paradigms namely the pathogenic and fortogenic paradigm. In the concept *"illness care"* it is suggested that a pathology is already present and the main focus is to cure the problem. In the case of *illness prevention* no pathology existed, only the threat of a pathology is present (immunisation against a certain illness such as polio is a typical example). In both constructs, because pathology forms the main focus of the treatment, the traditional health care professionals such as doctors, nurses and physiotherapists may be mainly responsible for treatment. In the *health promotion* construct no pathology or threat is present, and the aim is purely to improve health and well-being. This construct falls exclusively within the fortogenic paradigm where the aim is primarily to improve health and well-being by taking self-responsibility. As stated earlier the primary focus of Kinderkinetics falls in this paradigm. However, it is important to understand that the application of this discipline is also relevant in the pathogenic paradigm where the

actions may be more of therapeutic value indicated by areas that overlap (Fig 2).

Area A (Fig 2) would, therefore, suggest the rehabilitation or improvement of a pre-diagnosed condition. A child suffering from type 1 diabetes mellitus (which is associated with obesity) is a typical example in this scenario. While the pathology is medically treated and managed by the traditional health care professionals, the young child is motivated to participate in scientifically designed exercise programmes, tailored for his/her developmental needs, taking into account the barriers imposed on the child by the specific pathological condition. By participating in physical activity the pathology (type 1 diabetes) will not be totally cured but

al., 2009)

continuum and health paradigm, it is important to discuss the illness/well-being continuum briefly and its position in the various health paradigms viz. the pathogenic and fortogenic paradigm. This will provide the reader with a better understanding of where practitioners that treat childhood obesity are positioned in this health paradigm and of the specialized training and skills that such practitioners need to treat this condition effectively.

### **6.1 The health paradigms – A conceptualisation**

The World Health Organisation (WHO) already postulated a definition of health in 1947 indicating that "Health is a condition of optimal physical, psychological and social wellbeing and not merely the absence of disease". From this definition it is clear that illness and well-being focus on two different entities in the individual's health and well-being. This is clearly illustrated in the illness/well-being continuum as illustrated by Robbins et al. (1991)(Fig 1.).

Fig. 1. The illness/well being continuum (Robbins et al., 1991)

In the past the responsibility for the individual's health was solely the responsibility of the doctor. When any signs, symptoms and illness occurred the patient went to the doctor for medical attention in order treat the signs/symptoms and to restore life to the neutral point where no signs of the illness is noticeable. However, in this scenario no effort is being made from the patient's side to improve his own health and well-being by embracing a healthy lifestyle such as healthy eating habits and regular exercise.

To combat the problem of obesity among children, the primary focus should be on the right hand side of the continuum (Fig. 1). This comprises of providing the child with the necessary developmentally appropriate motor skills and creating an understanding of healthy behaviour and convert the knowledge and behaviour into effective strategies for health enhancement (Crawford, 2008), hereby educating the child and allowing him/her to grow to eventually accept self-responsibility for his/her own well-being. It is in this respect that Dr Koop, former Surgeon General of the USA, suggested that this health and well-being "message" should reach the very young child in order to develop healthy lifestyle habits. It is, therefore, clear that the main focus of a profession dealing with childhood obesity should fall on the right hand side of the continuum, which is focused on health promotion and, therefore, primarily can be described in the fortogenic paradigm which seeks "strong" (healthy) points to be enhanced ('Forte' means 'strong'). To understand the role of pediatric exercise science in the various health paradigms, the following conceptualisation (Fig. 2) may be useful.

continuum and health paradigm, it is important to discuss the illness/well-being continuum briefly and its position in the various health paradigms viz. the pathogenic and fortogenic paradigm. This will provide the reader with a better understanding of where practitioners that treat childhood obesity are positioned in this health paradigm and of the specialized

The World Health Organisation (WHO) already postulated a definition of health in 1947 indicating that "Health is a condition of optimal physical, psychological and social wellbeing and not merely the absence of disease". From this definition it is clear that illness and well-being focus on two different entities in the individual's health and well-being. This is clearly illustrated in the illness/well-being continuum as illustrated by Robbins et al.

In the past the responsibility for the individual's health was solely the responsibility of the doctor. When any signs, symptoms and illness occurred the patient went to the doctor for medical attention in order treat the signs/symptoms and to restore life to the neutral point where no signs of the illness is noticeable. However, in this scenario no effort is being made from the patient's side to improve his own health and well-being by embracing a healthy

To combat the problem of obesity among children, the primary focus should be on the right hand side of the continuum (Fig. 1). This comprises of providing the child with the necessary developmentally appropriate motor skills and creating an understanding of healthy behaviour and convert the knowledge and behaviour into effective strategies for health enhancement (Crawford, 2008), hereby educating the child and allowing him/her to grow to eventually accept self-responsibility for his/her own well-being. It is in this respect that Dr Koop, former Surgeon General of the USA, suggested that this health and well-being "message" should reach the very young child in order to develop healthy lifestyle habits. It is, therefore, clear that the main focus of a profession dealing with childhood obesity should fall on the right hand side of the continuum, which is focused on health promotion and, therefore, primarily can be described in the fortogenic paradigm which seeks "strong" (healthy) points to be enhanced ('Forte' means 'strong'). To understand the role of pediatric exercise science in the various

training and skills that such practitioners need to treat this condition effectively.

**6.1 The health paradigms – A conceptualisation**

Fig. 1. The illness/well being continuum (Robbins et al., 1991)

lifestyle such as healthy eating habits and regular exercise.

health paradigms, the following conceptualisation (Fig. 2) may be useful.

(1991)(Fig 1.).

Fig. 2. The role of kinderkinetics in the various health paradigms (Adapted from Strydom et al., 2009)

In Fig. 2, the three constructs regarding health, viz, *illness care, illness prevention* and *health promotion* are arranged into the two paradigms namely the pathogenic and fortogenic paradigm. In the concept *"illness care"* it is suggested that a pathology is already present and the main focus is to cure the problem. In the case of *illness prevention* no pathology existed, only the threat of a pathology is present (immunisation against a certain illness such as polio is a typical example). In both constructs, because pathology forms the main focus of the treatment, the traditional health care professionals such as doctors, nurses and physiotherapists may be mainly responsible for treatment. In the *health promotion* construct no pathology or threat is present, and the aim is purely to improve health and well-being. This construct falls exclusively within the fortogenic paradigm where the aim is primarily to improve health and well-being by taking self-responsibility. As stated earlier the primary focus of Kinderkinetics falls in this paradigm. However, it is important to understand that the application of this discipline is also relevant in the pathogenic paradigm where the actions may be more of therapeutic value indicated by areas that overlap (Fig 2).

Area A (Fig 2) would, therefore, suggest the rehabilitation or improvement of a pre-diagnosed condition. A child suffering from type 1 diabetes mellitus (which is associated with obesity) is a typical example in this scenario. While the pathology is medically treated and managed by the traditional health care professionals, the young child is motivated to participate in scientifically designed exercise programmes, tailored for his/her developmental needs, taking into account the barriers imposed on the child by the specific pathological condition. By participating in physical activity the pathology (type 1 diabetes) will not be totally cured but

Childhood Obesity: The Need for Practice Based Solutions – A South African Perspective 203

It seems that multi-disciplinary interventions that include physical activity, diet and behaviour modification, contributed to better results in comparison to studies that only focused on singular aspects. School-based programmes are found to be effective in combatting obesity by increasing the physical activity levels of the children and improving healthy eating habits. It can, therefore, be concluded that physical activity plays an important role in the prevention and treatment of overweight and obesity and the the type

The treatment of established obesity is, however, more complex and needs more intensive treatment. Clinical intervention based on a multi-disciplinary approach seems to be succesful (Eliakim et al., 2002; Nemene et al., 2005; Sacher et al., 2005; Korsten-Reck et al., 2005; Dreimane, et al., 2007; Eneli et al., 2008; Knöpfli et al., 2008; Weigel et al., 2008). It is also reported that interventions are more successful when the child is motivated to lose weight (Boon & Clydesdale, 2005), and that interventions on obese children with concerned parents are more successful than for instance school-based multi-disciplinary interventions where children sometimes are not even aware of the fact that they have a weight problem. Studies indicated that at least 12 weeks and a frequency of 3-5 times per week are required to provoke positive effects. Most studies use weight loss as a precursor of the success of the treatment. However, it is reported that obesity intervention has more advantages than only a positive change in body composition. An overall decrease of the metabolic syndrome was for instance reported among 10 to 17-year old children with a mean body fat percentage of 37.5%, after an intensive 2-week in-patient intervention in which no changes were found in the body fat percentage (Chen et al., 2006). A literature review by Eneli et al. *(*2008) showed similar results with only a small change in BMI, although improvements were seen in the

Obesity treatment requires considerable lifestyle related modifications which has to be sustainable in order to be successful. The sustainability of the effects of childhood obesity treatment is however reported as poor. The maintenance of the effects after the treatment phase is therefor a major challenge to overcome (Crawford, 2008). It often happens that when a controlled treatment ends, which is usually in the form of research, children are expected to follow a home programme by themselves. A main challenge for obese children is then to stay committed to make time to participate in the prescribed regular daily physical activity of moderate to high intensity level for at least 30 minutes, on their own, and sometimes in an unsympathetic environment. In addition, their expectations and setting of realistic goals are usually unrealistic, and because of this they can easily become frustrated. A possible reason for this might be that children younger than 12 years are still in the preoperational and concrete mental-operations stages of cognitive development as described by Piaget (Sherrill, 2004). This implies less mature stages of thinking and reasoning without abstract thought. With regard to health behaviour, Crawford (2008) states that children in these stages of cognitive development will experience barriers to plan for the future because they cannot form mental images of the positive and negative consequences of certain health behaviours. These reasoning skills are in turn, needed to assume a more internal locus of control regarding their own personal health management choices. Children thus require different techniques to get them to take responsibility for their health. In addition they also tend to be more extrinsically motivated in general and it is not clear when they shift to a

of treatment as well as the intensity and duration of the activity are very important.

lipid profile, blood pressure and insulin resistance.

**6.2.2 Challenges**

the benefits of exercise for this condition are already well described. It may also motivates the child to lead a physically active life into adulthood, preventing various health threats associated with a sedentary lifestyle (hypokinetic diseases) and strive to improve quality of life. It may also be during this phase when the young child is introduced to physical activity that the perception that the illness which is present (diabetes) need not be an ordeal but that the child may lead a 'normal' and productive life and that it is his/her responsibility to follow the necessary precautions to manage the disability. In many cases the perception of the child being a "disabled" as a result of the illness is a major obstacle for the parents to overcome, as they tend to be overprotective of such a child. Participating in a specialized environment and in programmes conducted by specialised trained health professionals, the parents may have peace of mind that the person who is working with the child is adequately trained.

Area B (Fig. 2) suggests a situation where the child may suffer from a pre-diagnosed condition that may be positively affected by physical activity so that it may lead to a possible improvement of the condition. An example here is the obese child. An increase in physical activity may improve the condition and also lead to improvement of the child's well-being. In Area C no pathology is currently present but the threat existed, which may lead to health consequences if the problem is ignored. An example in this case is the clumsy child. If such children are not exposed to activity provided by a trained professional who can assess their developmental barriers and can treat them effectively by equipping them with appropriate motor skills, a love for activity and an understanding of the importance of an active lifestyle, the clumsy child may continue to withdraw himself from movement and physical activity, eventually suffering from various hypokinetic diseases later in life.

### **6.2 Evidence-based intervention – Successes, challenges and principles 6.2.1 Successes**

In this section the outcomes of different obesity intervention studies on children with regard to the nature, the extent, the successes and the challenges will be discussed briefly, after which important principles that can guide the intervention process will be highlighted. Campbell et al. (2001) reported a research environment that is still void of current statistical power to set clear guidelines for the prevention of obesity across a variety of risk groups. Obesity prevention is, however, recommended as the best strategy in the combatting of obesity among children (Bosch et al., 2004; Boon & Clydesdale, 2005), although in reality this strategy is not always possible. The literature describes obesity treatment in prevention or curative settings, and as treatment based on singular (physical activity, diet or behaviour modification) or multi-component aspects (combinations of the aforementioned three components). Furthermore, studies report the results of childhood obesity treatment in clinical, family or school based settings.

A systematic review of 7 studies (4 shorter and 3 over a longer period) by Campbell et al. (2001) and 28 studies by Connelly et al. (2007) (11 successfull, 17 unsuccessful) indicated mixed success rates. However, it was concluded by Connoly et al. (2007) that the factor that contributed most to the effectivenes of the treatment was compulsory physical activity with a moderate to high intensity. An overview by Jerum and Melnyk (2001) of randomised controlled studies that focused on the prevention of childhood obesity indicated that health workers such as doctors and nurses should play a more prominent role in the prevention of obesity and that multi-component treatments are more successful than single component treatment. The importance of parent involvement is also highligted over the whole spectrum of obesity intervention (Jerum & Melnyk, 2001; Golan et al., 2006).

It seems that multi-disciplinary interventions that include physical activity, diet and behaviour modification, contributed to better results in comparison to studies that only focused on singular aspects. School-based programmes are found to be effective in combatting obesity by increasing the physical activity levels of the children and improving healthy eating habits. It can, therefore, be concluded that physical activity plays an important role in the prevention and treatment of overweight and obesity and the the type of treatment as well as the intensity and duration of the activity are very important.

The treatment of established obesity is, however, more complex and needs more intensive treatment. Clinical intervention based on a multi-disciplinary approach seems to be succesful (Eliakim et al., 2002; Nemene et al., 2005; Sacher et al., 2005; Korsten-Reck et al., 2005; Dreimane, et al., 2007; Eneli et al., 2008; Knöpfli et al., 2008; Weigel et al., 2008). It is also reported that interventions are more successful when the child is motivated to lose weight (Boon & Clydesdale, 2005), and that interventions on obese children with concerned parents are more successful than for instance school-based multi-disciplinary interventions where children sometimes are not even aware of the fact that they have a weight problem. Studies indicated that at least 12 weeks and a frequency of 3-5 times per week are required to provoke positive effects. Most studies use weight loss as a precursor of the success of the treatment. However, it is reported that obesity intervention has more advantages than only a positive change in body composition. An overall decrease of the metabolic syndrome was for instance reported among 10 to 17-year old children with a mean body fat percentage of 37.5%, after an intensive 2-week in-patient intervention in which no changes were found in the body fat percentage (Chen et al., 2006). A literature review by Eneli et al. *(*2008) showed similar results with only a small change in BMI, although improvements were seen in the lipid profile, blood pressure and insulin resistance.

### **6.2.2 Challenges**

202 Childhood Obesity

the benefits of exercise for this condition are already well described. It may also motivates the child to lead a physically active life into adulthood, preventing various health threats associated with a sedentary lifestyle (hypokinetic diseases) and strive to improve quality of life. It may also be during this phase when the young child is introduced to physical activity that the perception that the illness which is present (diabetes) need not be an ordeal but that the child may lead a 'normal' and productive life and that it is his/her responsibility to follow the necessary precautions to manage the disability. In many cases the perception of the child being a "disabled" as a result of the illness is a major obstacle for the parents to overcome, as they tend to be overprotective of such a child. Participating in a specialized environment and in programmes conducted by specialised trained health professionals, the parents may have

Area B (Fig. 2) suggests a situation where the child may suffer from a pre-diagnosed condition that may be positively affected by physical activity so that it may lead to a possible improvement of the condition. An example here is the obese child. An increase in physical activity may improve the condition and also lead to improvement of the child's well-being. In Area C no pathology is currently present but the threat existed, which may lead to health consequences if the problem is ignored. An example in this case is the clumsy child. If such children are not exposed to activity provided by a trained professional who can assess their developmental barriers and can treat them effectively by equipping them with appropriate motor skills, a love for activity and an understanding of the importance of an active lifestyle, the clumsy child may continue to withdraw himself from movement and

peace of mind that the person who is working with the child is adequately trained.

physical activity, eventually suffering from various hypokinetic diseases later in life.

In this section the outcomes of different obesity intervention studies on children with regard to the nature, the extent, the successes and the challenges will be discussed briefly, after which important principles that can guide the intervention process will be highlighted. Campbell et al. (2001) reported a research environment that is still void of current statistical power to set clear guidelines for the prevention of obesity across a variety of risk groups. Obesity prevention is, however, recommended as the best strategy in the combatting of obesity among children (Bosch et al., 2004; Boon & Clydesdale, 2005), although in reality this strategy is not always possible. The literature describes obesity treatment in prevention or curative settings, and as treatment based on singular (physical activity, diet or behaviour modification) or multi-component aspects (combinations of the aforementioned three components). Furthermore, studies report

**6.2 Evidence-based intervention – Successes, challenges and principles**

the results of childhood obesity treatment in clinical, family or school based settings.

of obesity intervention (Jerum & Melnyk, 2001; Golan et al., 2006).

A systematic review of 7 studies (4 shorter and 3 over a longer period) by Campbell et al. (2001) and 28 studies by Connelly et al. (2007) (11 successfull, 17 unsuccessful) indicated mixed success rates. However, it was concluded by Connoly et al. (2007) that the factor that contributed most to the effectivenes of the treatment was compulsory physical activity with a moderate to high intensity. An overview by Jerum and Melnyk (2001) of randomised controlled studies that focused on the prevention of childhood obesity indicated that health workers such as doctors and nurses should play a more prominent role in the prevention of obesity and that multi-component treatments are more successful than single component treatment. The importance of parent involvement is also highligted over the whole spectrum

**6.2.1 Successes**

Obesity treatment requires considerable lifestyle related modifications which has to be sustainable in order to be successful. The sustainability of the effects of childhood obesity treatment is however reported as poor. The maintenance of the effects after the treatment phase is therefor a major challenge to overcome (Crawford, 2008). It often happens that when a controlled treatment ends, which is usually in the form of research, children are expected to follow a home programme by themselves. A main challenge for obese children is then to stay committed to make time to participate in the prescribed regular daily physical activity of moderate to high intensity level for at least 30 minutes, on their own, and sometimes in an unsympathetic environment. In addition, their expectations and setting of realistic goals are usually unrealistic, and because of this they can easily become frustrated. A possible reason for this might be that children younger than 12 years are still in the preoperational and concrete mental-operations stages of cognitive development as described by Piaget (Sherrill, 2004). This implies less mature stages of thinking and reasoning without abstract thought. With regard to health behaviour, Crawford (2008) states that children in these stages of cognitive development will experience barriers to plan for the future because they cannot form mental images of the positive and negative consequences of certain health behaviours. These reasoning skills are in turn, needed to assume a more internal locus of control regarding their own personal health management choices. Children thus require different techniques to get them to take responsibility for their health. In addition they also tend to be more extrinsically motivated in general and it is not clear when they shift to a

Childhood Obesity: The Need for Practice Based Solutions – A South African Perspective 205

10. Programmes should be properly monitored, evaluated and documented to ensure

Kruger et al. (2005) also report that the US Institutes of Medicine suggested three levels of

1. *Universal prevention* interventions, focused on everyone in an eligible population irrespective of their current level of risk. This may be family-based, school-based, work site-based or community-wide. Secondly, s*elective prevention* interventions, focusing on the prevention of obesity in selected high-risk groups, based on known biological, psychological or social/ cultural risk factors, which will focus on the development of lifetime behavioural patterns that will prevent obesity, and thirdly, t*argeted prevention* that focuses on individuals who are overweight and aims to prevent weight gain, as

Different modes of delivery of prevention programmes are also reported by Kruger et al.

1. *Do-it-yourself in self-initiated or group settings*. This self-help programmes are seen as lowintensity, cheaper intervention methods, associated with better longer term compliance

2. *Non-clinical programmes* provided to individuals/groups by trained professionals, not necessarily registered healthcare professionals. Information on diet, exercise and behaviour modification is provided at regular meetings. These programmes are popular

3. *Clinical programmes* provided by registered healthcare professionals with specialized training in weight management. These could involve a consultation with a dietician,

Kruger et al. (2005) finally stressed that all obesity treatment programmes should aim to empower individuals/groups to take responsibility for making permanent lifestyle changes towards healthy dietary intake and physical activity through behaviour modification, and recommend the inclusion of the following essential components in such programmes.

> Individualised, realistic, maintainable, contribute to general well-being. Based on the 2004 South African food-based dietary guidelines.

Accumulate 45–60 min of moderate-to-vigorous activity on

Long-term lifestyle (dietary and physical activity) changes;

communication and environment management, cognitive behavioural skills necessary to bring about change. To ensure success the 'stage of change' of the individual/ target group

most days – accumulating 10 min here and there is

self-concept, body image, stress management,

Increased physical activity of daily living, fitness and recreational activity, strength and flexibility exercises.

**Component Description/guidelines**

needs to be considered.

acceptable.

prevention to ensure the correct focus for obesity prevention which include:

but poorer weight loss outcomes than higher-intensity methods.

8. Integration of new programmes within existing initiatives.

9. Programme planning should be evidence-based.

dissemination and transfer of experience.

well as the development of co-morbidities.

and often commercially franchised.

medical doctor or a multi-disciplinary team.

(2005). These include:

Reasonable weight goals

Healthful eating component

Physical activity component

Behavioural and

psychological component

more internal motivation with regard to health goals (Crawford, 2008). As obese children are often negative towards participation in physical activities, this is a major challenge to overcome because of the importance of physical activity in their treatment. The content of the physical activity program should therefore be scientifically grounded but delivered in such a manner that the child will associate movement with enjoyment in order for this part of their treatment to provide enough external motivation to them to persist with it. Without a positive attitude towards participation in physical activity, it will be hard to motivate obese children to increase their activity levels and to stay active.

Furthermore, obese children with co-morbidities are at risk for contra-indications and should not participate in unsupervised physical activity programmes with high intensities which is required for weight loss. In addition, the development of age appropriate motor skills, strength, fitness and proper body posture are important goals in the treatment of obese children in order to equip them with the necessary motor repertoire based on their developmental level and abilities to be able to participate in sports programmes and recreational activities with their peers. They should therefore be assessed and a programme should be described to them based upon this assessment which is tailored to their specific needs. It is therefore imperative that the health care professional should have a thorough scientific background and understanding of the obese child regarding the physical, emotional, cognitive and physiological barriers these children have to deal with and which they have to overcome in order for an intervention to be sustainable and to contribute to permanent lifestyle changes. In this regard high levels of social support (network of family, friends, health professionals and community resources by providing appropriate information and encouragement) and self efficacy are indicated to be important predictors in adherence (Crawford, 2008).

### **6.2.3 Principles of prevention programmes**

Kruger et al. (2005) provide important recommendations and discussed various principles for the treatment of obesity in South Africa. However, the applicability of some of the recommendations will be more challenging and will need some adaptations to be effective when applied to children. They reported that at the first WHO Expert Consultation on Obesity, the development and implementation of effective obesity prevention strategies were identified as an immediate action priority. To guide this process, these researchers indicated that South African researchers and health workers should take note of the proposed principles upon which obesity prevention should be based. These principles will be used as a guide in the discussion of the way forward.

more internal motivation with regard to health goals (Crawford, 2008). As obese children are often negative towards participation in physical activities, this is a major challenge to overcome because of the importance of physical activity in their treatment. The content of the physical activity program should therefore be scientifically grounded but delivered in such a manner that the child will associate movement with enjoyment in order for this part of their treatment to provide enough external motivation to them to persist with it. Without a positive attitude towards participation in physical activity, it will be hard to motivate

Furthermore, obese children with co-morbidities are at risk for contra-indications and should not participate in unsupervised physical activity programmes with high intensities which is required for weight loss. In addition, the development of age appropriate motor skills, strength, fitness and proper body posture are important goals in the treatment of obese children in order to equip them with the necessary motor repertoire based on their developmental level and abilities to be able to participate in sports programmes and recreational activities with their peers. They should therefore be assessed and a programme should be described to them based upon this assessment which is tailored to their specific needs. It is therefore imperative that the health care professional should have a thorough scientific background and understanding of the obese child regarding the physical, emotional, cognitive and physiological barriers these children have to deal with and which they have to overcome in order for an intervention to be sustainable and to contribute to permanent lifestyle changes. In this regard high levels of social support (network of family, friends, health professionals and community resources by providing appropriate information and encouragement) and self efficacy are indicated to be important predictors

Kruger et al. (2005) provide important recommendations and discussed various principles for the treatment of obesity in South Africa. However, the applicability of some of the recommendations will be more challenging and will need some adaptations to be effective when applied to children. They reported that at the first WHO Expert Consultation on Obesity, the development and implementation of effective obesity prevention strategies were identified as an immediate action priority. To guide this process, these researchers indicated that South African researchers and health workers should take note of the proposed principles upon which obesity prevention should be based. These principles will

1. Interventions should focus on education and address environmental and social factors

3. Sustainability of programmes is crucial to ensure positive change in diet, activity and

4. Political support, inter-sectoral collaboration and community participation are essential

5. Local actions within the context of national initiatives allow programmes to meet needs,

obese children to increase their activity levels and to stay active.

in adherence (Crawford, 2008).

2. Increased physical activity.

obesity levels over time.

expectations and opportunities.

6. All parts of the population must be reached. 7. Programmes must be adequately resourced.

for success.

**6.2.3 Principles of prevention programmes**

be used as a guide in the discussion of the way forward.

to promote and support behaviour change.

10. Programmes should be properly monitored, evaluated and documented to ensure dissemination and transfer of experience.

Kruger et al. (2005) also report that the US Institutes of Medicine suggested three levels of prevention to ensure the correct focus for obesity prevention which include:

1. *Universal prevention* interventions, focused on everyone in an eligible population irrespective of their current level of risk. This may be family-based, school-based, work site-based or community-wide. Secondly, s*elective prevention* interventions, focusing on the prevention of obesity in selected high-risk groups, based on known biological, psychological or social/ cultural risk factors, which will focus on the development of lifetime behavioural patterns that will prevent obesity, and thirdly, t*argeted prevention* that focuses on individuals who are overweight and aims to prevent weight gain, as well as the development of co-morbidities.

Different modes of delivery of prevention programmes are also reported by Kruger et al. (2005). These include:

Kruger et al. (2005) finally stressed that all obesity treatment programmes should aim to empower individuals/groups to take responsibility for making permanent lifestyle changes towards healthy dietary intake and physical activity through behaviour modification, and recommend the inclusion of the following essential components in such programmes.

Childhood Obesity: The Need for Practice Based Solutions – A South African Perspective 207

guideline in determining the intensity level of the physical activity programme of obese children or with regard to daily physical activity that is expected from them, depending on their age (Table 1). Parizkova (2005) report in this regard that exercise must be vigorous enough to impose an adequate training load on the cardiorespiratory system, and stress that

Lastly with regard to the behavioural and psychological component of treatment programs, the immature cognitive understanding and reasoning skills of children as described earlier, might influence children's commitment to changes in their personal health management. The Academy for Eating disorders (2011) recommend that the ideal intervention should be based on an integrated approach that addresses risk factors for the spectrum of weight-related problems, including screening for unhealthy weight control behaviours; and promotes protective behaviours, such as decreasing dieting, increasing balanced nutrition, encouraging mindful eating, increasing activity, promoting positive body image and decreasing weight-related teasing and harassment. Behavioural changes that are expected from them should, therefore, be carefully managed. The AED (2011) also recommend that interventions should also be created and led by qualified health care providers who acknowledge the importance of a health focus over a weight focus when targeting lifestyle and weight concerns in youth. In this regard, the modes of delivery of prevention programmes as suggested by Kruger et al. (2005), will also be challenging for children because they are mostly based on selfhelp programmes and the implementation of knowledge gained from regular meetings. Delivery of programmes in this way will be challenging for children to comply with or to understand. Sustainable programmes, especially with regard to physical activity, managed by a trained health care professional who understands the limitations of children and who can adress it appropriately within a supportive family environment (Steyn 2007), might be the

only workable solutions to adress these developmental deficiencies of children.

**Adolescents (13-17)** 3-5 days per week

**(10-12)** 4-7 days per week

**Younger children (6-9)** 4-7 days per week

No change unless disability can be exacerbated by regular

activity

Table 1. Guidelines for developing aerobic functioning

**Older children**

**Adjustments for youngsters with diabetes**

levels at times.

**Group Frequency Intensity Duration**

55-90% HR max (115-180 beats/min)

55-70% HR max (115-145 beats/min)

De-emphasized; participants is encouraged

Reduced as a function of fitness level; adjust THRZ for individuals using arms-only activity and for individuals with SCI quadriplegia

20-60min per day (accumulated: >10 min

30-60+min per day (accumulate, intermittent)

30-60min+min per day (accumulate, intermittent)

Accumulate more intermittent activity or reduce total time if

necessary

per bout)

12-16 RPE 10-15METs

12-13 RPE 5-7METs

\*These values represent moderate physical activity; ideally, this level will be exceeded to vigorous

this part of a programme should be adequately monitored.

For effective implementation of the above treatment principles among children, specific recommendations should, however, be *added* with regard to the *weight goals and eating habits* and *physical activity components* because children have developmental limitations on different levels. With regard to weight goals and healthy eating patterns, it should be remembered that children's bodies are in a growing phase and that weight loss will not necessarily be the most suitable goal, depending on the extent of the obesity problem. Although individual differences and circumstances should always be taken into consideration, it is suggested that the eating habits and patterns of young children should rather be managed by lifestyle changes which incorporate changing of eating habits rather than they being expected to follow a strict diet. Steyn (2007) reports in this regard the National guidelines of the Department of Health which states that the weight of children aged between 2 and 7 years who have no complications should be maintained, because there will be weight loss as a result of an increase in length. If there are however, complications such as high blood pressure, insulin resistance or orthopaedic problems, weight loss will be necessary. In children over 7 years, weight loss should be started when the BMI of the child' lies above the 95th percentile, or otherwise the international age specific cut-off values for obesity of Cole et al. (2000) can be used as a quick screening method. The AED (2011) also recommends that interventions should aim for the maintenance of individually appropriate weights, that is, that children will continue to grow at their natural rate and follow their own growth curve, underscoring that a healthy weight is not a fixed number but varies for each individual. The South African version of the stoplight (robot) diet is suggested for use among children towards healthier dietary intake (Steyn, 2007). Foods are categorised in this diet in categories of use, in limited, moderate or restricted amounts, and parents and children are asked to keep record of all that is eaten, which makes them aware of the quantity and quality of foods being consumed. The guidelines of the ACSM (2000) for the structuring of obesity programmes are also valuable with regard to the weight and eating management of obese children. This includes a recomendation of maintaining a minimal intake of about 1200 calories per day, and engaging in a daily exercise program that expends 300 or more calories per day. For weight-loss goals, exercise of long duration /moderate intensity is generally considered best (ACSM, 2000). The AED (2011) highlights that weight is not a behaviour and therefore not an appropriate target for behaviour modification in school and community based intervetions. They recommend that interventions should be weight-neutral, thus not have specific goals for weight change but aim to increase healthy living at any size. Children across the weight spectrum benefit from limiting time spent watching television and eating a healthy diet.Children therefore need education to understand what realistic goals are with regard to weight management and that they will have to make a commitment to adhere to their goals, also with regard to participating in physical activity.

Regarding the guidelines for physical activity component of treatment programmes, the developmental needs of obese children regarding their motor skills development or the lack of it because of their overweight problem, should receive attention. This is a unique requirement of childhood treatment programmes in comparison to adult programmes. The activities included in a programme, therefore, need to focus on increased levels of participation in conjunction with opportunities to enhance basic motor skills that are needed for sport participation or recreational activities. Weight bearing activities which can improve bone health should also be included in the activity programme. Guidelines as suggested by Short et al. (1999) for aerobic functioning among 6-17 year old children can be use as a

For effective implementation of the above treatment principles among children, specific recommendations should, however, be *added* with regard to the *weight goals and eating habits* and *physical activity components* because children have developmental limitations on different levels. With regard to weight goals and healthy eating patterns, it should be remembered that children's bodies are in a growing phase and that weight loss will not necessarily be the most suitable goal, depending on the extent of the obesity problem. Although individual differences and circumstances should always be taken into consideration, it is suggested that the eating habits and patterns of young children should rather be managed by lifestyle changes which incorporate changing of eating habits rather than they being expected to follow a strict diet. Steyn (2007) reports in this regard the National guidelines of the Department of Health which states that the weight of children aged between 2 and 7 years who have no complications should be maintained, because there will be weight loss as a result of an increase in length. If there are however, complications such as high blood pressure, insulin resistance or orthopaedic problems, weight loss will be necessary. In children over 7 years, weight loss should be started when the BMI of the child' lies above the 95th percentile, or otherwise the international age specific cut-off values for obesity of Cole et al. (2000) can be used as a quick screening method. The AED (2011) also recommends that interventions should aim for the maintenance of individually appropriate weights, that is, that children will continue to grow at their natural rate and follow their own growth curve, underscoring that a healthy weight is not a fixed number but varies for each individual. The South African version of the stoplight (robot) diet is suggested for use among children towards healthier dietary intake (Steyn, 2007). Foods are categorised in this diet in categories of use, in limited, moderate or restricted amounts, and parents and children are asked to keep record of all that is eaten, which makes them aware of the quantity and quality of foods being consumed. The guidelines of the ACSM (2000) for the structuring of obesity programmes are also valuable with regard to the weight and eating management of obese children. This includes a recomendation of maintaining a minimal intake of about 1200 calories per day, and engaging in a daily exercise program that expends 300 or more calories per day. For weight-loss goals, exercise of long duration /moderate intensity is generally considered best (ACSM, 2000). The AED (2011) highlights that weight is not a behaviour and therefore not an appropriate target for behaviour modification in school and community based intervetions. They recommend that interventions should be weight-neutral, thus not have specific goals for weight change but aim to increase healthy living at any size. Children across the weight spectrum benefit from limiting time spent watching television and eating a healthy diet.Children therefore need education to understand what realistic goals are with regard to weight management and that they will have to make a commitment to adhere to their goals, also with regard to participating in physical

Regarding the guidelines for physical activity component of treatment programmes, the developmental needs of obese children regarding their motor skills development or the lack of it because of their overweight problem, should receive attention. This is a unique requirement of childhood treatment programmes in comparison to adult programmes. The activities included in a programme, therefore, need to focus on increased levels of participation in conjunction with opportunities to enhance basic motor skills that are needed for sport participation or recreational activities. Weight bearing activities which can improve bone health should also be included in the activity programme. Guidelines as suggested by Short et al. (1999) for aerobic functioning among 6-17 year old children can be use as a

activity.

guideline in determining the intensity level of the physical activity programme of obese children or with regard to daily physical activity that is expected from them, depending on their age (Table 1). Parizkova (2005) report in this regard that exercise must be vigorous enough to impose an adequate training load on the cardiorespiratory system, and stress that this part of a programme should be adequately monitored.

Lastly with regard to the behavioural and psychological component of treatment programs, the immature cognitive understanding and reasoning skills of children as described earlier, might influence children's commitment to changes in their personal health management. The Academy for Eating disorders (2011) recommend that the ideal intervention should be based on an integrated approach that addresses risk factors for the spectrum of weight-related problems, including screening for unhealthy weight control behaviours; and promotes protective behaviours, such as decreasing dieting, increasing balanced nutrition, encouraging mindful eating, increasing activity, promoting positive body image and decreasing weight-related teasing and harassment. Behavioural changes that are expected from them should, therefore, be carefully managed. The AED (2011) also recommend that interventions should also be created and led by qualified health care providers who acknowledge the importance of a health focus over a weight focus when targeting lifestyle and weight concerns in youth. In this regard, the modes of delivery of prevention programmes as suggested by Kruger et al. (2005), will also be challenging for children because they are mostly based on selfhelp programmes and the implementation of knowledge gained from regular meetings. Delivery of programmes in this way will be challenging for children to comply with or to understand. Sustainable programmes, especially with regard to physical activity, managed by a trained health care professional who understands the limitations of children and who can adress it appropriately within a supportive family environment (Steyn 2007), might be the only workable solutions to adress these developmental deficiencies of children.

\*These values represent moderate physical activity; ideally, this level will be exceeded to vigorous levels at times.

Table 1. Guidelines for developing aerobic functioning

Childhood Obesity: The Need for Practice Based Solutions – A South African Perspective 209

conducts the programme. The basic and underlying philosophy of treatment in this regard is to expose the young child to physical activity adapted to his/her individual needs while creating a child-friendly atmosphere. In this environment professionally trained individuals have to support and motivate the child to participate and enjoy the prescribed activities within a scientifically based programme. If any health risks associated with obesity such as hypertension or other cardiovascular risks are identified during the initial screening process, such a child should be referred to a medical practitioner who has to clear the child clinically

This approach calls for a comprehensive strategy managed by an appropriately qualified professional. In South Africa a new field of study has developed over the past 2 decades, seeking to bridge the gap between research and implementation. From this field of study a "new health profession" has emerged, called "Kinderkinetics" – derived from the terms "kinder" as in "children" and "kinesis" as in "movement". The focus of this profession primarily falls on the field of pediatric exercise science – using exercise/activity as a

Students in this profession are trained at 4 South African Universities/tertiary institutions following a 4 year degree integrated with laboratory and practical experience in various centres, which requires hands-on experience in order to obtain professional registration. At present, qualified professionals are registered by a professional body, the South African Professional Institute for Kinderkinetics (SAPIK) to practice as Kinderkineticists. The scope of this discipline falls primarily within the health promotion paradigm (fortogenic), providing scientifically-based exercise programmes to stimulate the young child according to his/her psycho-physical developmental stage in order to obtain optimal development. However, the scope also includes children with pre-diagnosed clinical problems such as obesity, diabetes mellitus, HIV, Down Syndrome and other ailments where children may have special needs and/or barriers regarding their physical activity and motor

This fairly new discipline (Kinderkinetics) has already gained substantial recognition as a potential health discipline and more than 150 practitioners are already working in this field, ranging from self-employment in private practices to employment in school and pre-school environment. In practice many referrals are received from other health professionals, such as paediatricians, general practitioners, occupational therapists, teachers and parents. The SAPIK is currently in the process of applying for official recognition of this profession from a Statutory Health Professions Council in South Africa in order to ethically legalise referrals from other health practitioners mentioned, as ethical rules of those health professionals prohibit mutual referral and cooperation between registered versus unregistered practitioners. These negotiations with the Statutory Health Professions Council are already in an advance stage and will hopefully

The profession of Kinderkinetics is guided by applied research where the growth and motor development and physical activity of children, as well as interventions to improve shortcomings that are identified in this regard, have already been extensively researched within the field of pediatric exercise science. In this regard obesity among children of different age groups and from different perspectives for a better understanding of the

for participation in an exercise programme.

therapeuticum, profilaticum and health promotion modality.

development, hence overlapping in the pathogenic paradigm.

be successful.

**7.1.1 Applied research**

Reprinted, by permission, from F.X. Short, J. McCubbin, and G. Frey, 1999, Cardiorespiratory endurance and body composition. In *The Brockport physical fitness training guide,* edited by J.P. Winnick and F.X. Short (Champaign, IL: Human Kinetics).

### **7. Practice-based solutions – The way forward**

As described, childhood obesity is a challenging problem to combat especially in a country like South Africa where the health care system is challenged with numerous complexities. From the above discussion it is clear that it is important to intervene at a young age in order to establish a healthy lifestyle among children. However, children cannot be treated as miniadults, because of their developmental needs and limitations on various levels that have to be taken into consideration when addressing this problem. Intervention of childhood obesity (prevention and treatment), therefore, calls for comprehensive and innovative strategies. A few practice-based solutions that are implemented successfully in this country will be discussed in the following section.

### **7.1 Paediatric exercise science – The development of a new health care profession in South Africa**

In combating the obesity epidemic among children, an increase in physical activity plays an important role, both in primary and secondary intervention. A real challenge is to provide evidence-based physical activity intervention to children during early childhood (3-12 years). For the very young child, a physical activity intervention should be age and developmentally appropriate. Therefore, the professional who administers the intervention during this stage should be thoroughly trained in childhood development and paediatric exercise science. The literature has already indicated a gap between evidence-based research and practice-based intervention (Robert Wood Johnson Foundation, 2008). It is often seen that when researchers have published the results of their intervention studies or clinical trials, they walk away totally satisfied with positive and promising results. The challenge, however, remains for somebody to translate these research results for practitioners to be used as "tools" in addressing the existing problem.

The treatment offered should be based on an individual assessment of each child and then tailored to the requirements of the developmental stage and the severity of the problem. This should *i.a* include the following: obtaining a medical and family history, a physical activity profile and information about the eating habits of the child to determine possible reasons for his overweight problem. Situational influences relevant to the health behaviour such as cultural influences should also be taken into consideration. Secondly, his body composition (weight, height, hip and waist-circumferences, skinfolds and BMI), current motor and physical abilities (strength, strength endurance, cardiovascular endurance and flexibility) and basic motor skills needed for sport participation as well as his body posture should be assessed to determine individual goals for treatment. Thirdly, the baseline principles of intervention strategy with regard to frequency, duration, mode of delivery and type of activities should be followed (Parizkova, 2005). Older children may be requested to select preferred sporting activities that can be included as a part of their treatment regime in order to make it more enjoyable for them making them feel part of the decision making process of their treatment. Such a programme should be offered in a controlled and childfriendly environment with considerable support from the health care professional who conducts the programme. The basic and underlying philosophy of treatment in this regard is to expose the young child to physical activity adapted to his/her individual needs while creating a child-friendly atmosphere. In this environment professionally trained individuals have to support and motivate the child to participate and enjoy the prescribed activities within a scientifically based programme. If any health risks associated with obesity such as hypertension or other cardiovascular risks are identified during the initial screening process, such a child should be referred to a medical practitioner who has to clear the child clinically for participation in an exercise programme.

This approach calls for a comprehensive strategy managed by an appropriately qualified professional. In South Africa a new field of study has developed over the past 2 decades, seeking to bridge the gap between research and implementation. From this field of study a "new health profession" has emerged, called "Kinderkinetics" – derived from the terms "kinder" as in "children" and "kinesis" as in "movement". The focus of this profession primarily falls on the field of pediatric exercise science – using exercise/activity as a therapeuticum, profilaticum and health promotion modality.

Students in this profession are trained at 4 South African Universities/tertiary institutions following a 4 year degree integrated with laboratory and practical experience in various centres, which requires hands-on experience in order to obtain professional registration. At present, qualified professionals are registered by a professional body, the South African Professional Institute for Kinderkinetics (SAPIK) to practice as Kinderkineticists. The scope of this discipline falls primarily within the health promotion paradigm (fortogenic), providing scientifically-based exercise programmes to stimulate the young child according to his/her psycho-physical developmental stage in order to obtain optimal development. However, the scope also includes children with pre-diagnosed clinical problems such as obesity, diabetes mellitus, HIV, Down Syndrome and other ailments where children may have special needs and/or barriers regarding their physical activity and motor development, hence overlapping in the pathogenic paradigm.

This fairly new discipline (Kinderkinetics) has already gained substantial recognition as a potential health discipline and more than 150 practitioners are already working in this field, ranging from self-employment in private practices to employment in school and pre-school environment. In practice many referrals are received from other health professionals, such as paediatricians, general practitioners, occupational therapists, teachers and parents. The SAPIK is currently in the process of applying for official recognition of this profession from a Statutory Health Professions Council in South Africa in order to ethically legalise referrals from other health practitioners mentioned, as ethical rules of those health professionals prohibit mutual referral and cooperation between registered versus unregistered practitioners. These negotiations with the Statutory Health Professions Council are already in an advance stage and will hopefully be successful.

### **7.1.1 Applied research**

208 Childhood Obesity

Reprinted, by permission, from F.X. Short, J. McCubbin, and G. Frey, 1999, Cardiorespiratory endurance and body composition. In *The Brockport physical fitness training*

As described, childhood obesity is a challenging problem to combat especially in a country like South Africa where the health care system is challenged with numerous complexities. From the above discussion it is clear that it is important to intervene at a young age in order to establish a healthy lifestyle among children. However, children cannot be treated as miniadults, because of their developmental needs and limitations on various levels that have to be taken into consideration when addressing this problem. Intervention of childhood obesity (prevention and treatment), therefore, calls for comprehensive and innovative strategies. A few practice-based solutions that are implemented successfully in this country

**7.1 Paediatric exercise science – The development of a new health care profession in**

In combating the obesity epidemic among children, an increase in physical activity plays an important role, both in primary and secondary intervention. A real challenge is to provide evidence-based physical activity intervention to children during early childhood (3-12 years). For the very young child, a physical activity intervention should be age and developmentally appropriate. Therefore, the professional who administers the intervention during this stage should be thoroughly trained in childhood development and paediatric exercise science. The literature has already indicated a gap between evidence-based research and practice-based intervention (Robert Wood Johnson Foundation, 2008). It is often seen that when researchers have published the results of their intervention studies or clinical trials, they walk away totally satisfied with positive and promising results. The challenge, however, remains for somebody to translate these research results for practitioners to be

The treatment offered should be based on an individual assessment of each child and then tailored to the requirements of the developmental stage and the severity of the problem. This should *i.a* include the following: obtaining a medical and family history, a physical activity profile and information about the eating habits of the child to determine possible reasons for his overweight problem. Situational influences relevant to the health behaviour such as cultural influences should also be taken into consideration. Secondly, his body composition (weight, height, hip and waist-circumferences, skinfolds and BMI), current motor and physical abilities (strength, strength endurance, cardiovascular endurance and flexibility) and basic motor skills needed for sport participation as well as his body posture should be assessed to determine individual goals for treatment. Thirdly, the baseline principles of intervention strategy with regard to frequency, duration, mode of delivery and type of activities should be followed (Parizkova, 2005). Older children may be requested to select preferred sporting activities that can be included as a part of their treatment regime in order to make it more enjoyable for them making them feel part of the decision making process of their treatment. Such a programme should be offered in a controlled and childfriendly environment with considerable support from the health care professional who

*guide,* edited by J.P. Winnick and F.X. Short (Champaign, IL: Human Kinetics).

**7. Practice-based solutions – The way forward**

will be discussed in the following section.

used as "tools" in addressing the existing problem.

**South Africa**

The profession of Kinderkinetics is guided by applied research where the growth and motor development and physical activity of children, as well as interventions to improve shortcomings that are identified in this regard, have already been extensively researched within the field of pediatric exercise science. In this regard obesity among children of different age groups and from different perspectives for a better understanding of the

Childhood Obesity: The Need for Practice Based Solutions – A South African Perspective 211

have to be national initiatives acknowledging the severity of the problem, policy support and community engagement on the level of implementation. The training of mid-level professionals, who can assist the Kinderkineticist in the screening and recruiting process and in the sustainability of programmes by supervising and monitoring it is essential. The training of such workers is envisaged as a sub-register that will be part of the professional registration of Kinderkinetics in the future. The training of multi-skilled professionals who can work multi-disciplinary with the Kinderkineticists such as nurses in health care clinics or in the school system or of Life Orientation teachers who can do screening for abnormalities, is also a possibility to ensure early identification and referral of obese

The important message of obesity prevention by embracing a healthy lifestyle should be echoed through the school system, as most children can be reached through the school curriculum. The AED (2011) recommends that interventions should not be marketed as "obesity prevention", but rather interventions should be referred to as "health promotion," as the ultimate goal is the health and well-being of all children, and health encompasses many factors besides weight. Physical education (PE) was, however, phased out of South African schools to make more time available for the "so-called" academic subjects, and with that, teachers with the necessary training to make children aware of the importance of a healthy lifestyle and to provide them with the necessary skills and physical activity, also declined. Since 2010 PE was reinstated in the school curriculum where this message can be portrayed, and screening for overweight can be done with the necessary education or referral for help. Interventions should focus on making children's environments healthier rather than focusing solely on personal responsibility, which include serving healthy meals, providing opportunities for fun physical activities, implementing a no-teasing policy, and providing students and school staff with educational sessions about body image, media literacy, and weight bias (AED, 2011). However, this is going to be a long process as teachers for this profession have to be trained from scratch and schools have to be equipped with the necessary resources to

Kruger et al. (2005) report that lifestyle modification as an isolated tool for weight management has a high drop-out rate with less than 5% of patients remaining successful after 5 years. If lifestyle modification is this challenging to adults, young children will need much more encouragement, support and supervision to change their lifestyle because of their poorer cognitive understanding of the consequences of the problem of overweight and hence the lack of self-responsibility and commitment to do something about it. It can, therefore, hardly be expected from overweight and obese children to comply with a treatment programme which includes lifestyle modifications including physical activity, dietary and behaviour modification on different levels, on their own. Health promotion awareness campaigns that urge children to be more active because of the health consequences of physical inactivity will hence not be enough to motivate them to become more active and stay active. Practitioners need to design programmes and apply it in such a way that it is attractive to these children and thereby motivate them to

children, as well as of other children at-risk for developmental problems.

**7.2 Obesity prevention**

teach this subject effectively.

**7.3 Improved sustainability of obesity intervention**

problem have been published. This *i.a* include the prevalence of childhood obesity in different age groups (Du Toit & Pienaar, 2003), relationship of childhood obesity with the motor (Du Toit & Pienaar, 2003); fitness, (Truter et al., 2010); psychological (Pienaar & Eggar, 2007; Kemp & Pienaar, 2010), physiological (Kemp & Pienaar, 2010) and academic abilities (Du Toit et al., 2011), as well as relationships of obesity with diagnosed motor delays such as Developmental Coordination Disorder among children (Pienaar et al., 2007). The most recent study that will be published shortly indicates significant relationships between hypertension, overweight and obesity among a representative group of 7-year old children in this country (Kemp et al. 2011, in press).

After accumulating all this evidence, the next action taken was the planning of research in which an obesity intervention programme could be developed and assessed. A programme based on the principles of physical activity participation, behaviour modification and dietary guidelines was then compiled and the outcomes evaluated. The energy expenditure of the group was monitored by Actical software in order to determine the effectiveness of the intensity of the physical activity part of the programme, but also to analyse the activity patterns of the children during the week and weekend and to determine possible changes in their activity patterns resulting from the programme. This intervention on 9-12 year old children was conducted over a period of 13 weeks at a frequency of three times per week with a home program and parent meetings regarding school lunch boxes and physical activity guidelines. The physical activity intervention was delivered on two days of the week, while behaviour modification regarding their eating patterns, self perception and physical activity habits was the focus of the third day of the week. Dietary modification by means of empowering the children with knowledge of different foods, healthy eating patterns, improvement of self-perception and goal setting strategies to improve physical activity were addressed through play and activity themes on this day. A home program was provided to them that they had to follow for the two additional days of the week. Significant improvement was found in the children's body composition (body fat percentage) while, waist- and upper arm-circumferences decreased significantly. A non-significant decrease of 2.9 kg was also found in body weight. The self-perception of the group improved significantly as assessed by the Harter Scale (Kemp & Pienaar, 2010). The compliance to the programme decreased when the supervised part ended, again highlighting the need for professional supervision and sustained motivation of children in obesity treatment regimens. This protocol is now implemented as an obese intervention by Kinderkineticists, with specific adjustments with regard to age appropriateness of the level, selection and inclusion of motor activities and the intensity level of physical activities. The treatment programme can also be used effectively for inactive children by only modifying the intensity of the programme, as it incorporates all the necessary fitness components such as strength and strength endurance, cardiovascular endurance, flexibility and the development of basic motor skills needed for sport participation.

### **7.1.2 Implementation**

The need for the expertise, provided by this discipline in this country with its extreme diversity, not only in population and ethnic groupings, but also in socio-economic status, is substantial. Challenges to bring this service to the deep-rural and remote areas of the country still ask for innovative thinking. A first step in childhood obesity treatment will have to be national initiatives acknowledging the severity of the problem, policy support and community engagement on the level of implementation. The training of mid-level professionals, who can assist the Kinderkineticist in the screening and recruiting process and in the sustainability of programmes by supervising and monitoring it is essential. The training of such workers is envisaged as a sub-register that will be part of the professional registration of Kinderkinetics in the future. The training of multi-skilled professionals who can work multi-disciplinary with the Kinderkineticists such as nurses in health care clinics or in the school system or of Life Orientation teachers who can do screening for abnormalities, is also a possibility to ensure early identification and referral of obese children, as well as of other children at-risk for developmental problems.

### **7.2 Obesity prevention**

210 Childhood Obesity

problem have been published. This *i.a* include the prevalence of childhood obesity in different age groups (Du Toit & Pienaar, 2003), relationship of childhood obesity with the motor (Du Toit & Pienaar, 2003); fitness, (Truter et al., 2010); psychological (Pienaar & Eggar, 2007; Kemp & Pienaar, 2010), physiological (Kemp & Pienaar, 2010) and academic abilities (Du Toit et al., 2011), as well as relationships of obesity with diagnosed motor delays such as Developmental Coordination Disorder among children (Pienaar et al., 2007). The most recent study that will be published shortly indicates significant relationships between hypertension, overweight and obesity among a representative group of 7-year old

After accumulating all this evidence, the next action taken was the planning of research in which an obesity intervention programme could be developed and assessed. A programme based on the principles of physical activity participation, behaviour modification and dietary guidelines was then compiled and the outcomes evaluated. The energy expenditure of the group was monitored by Actical software in order to determine the effectiveness of the intensity of the physical activity part of the programme, but also to analyse the activity patterns of the children during the week and weekend and to determine possible changes in their activity patterns resulting from the programme. This intervention on 9-12 year old children was conducted over a period of 13 weeks at a frequency of three times per week with a home program and parent meetings regarding school lunch boxes and physical activity guidelines. The physical activity intervention was delivered on two days of the week, while behaviour modification regarding their eating patterns, self perception and physical activity habits was the focus of the third day of the week. Dietary modification by means of empowering the children with knowledge of different foods, healthy eating patterns, improvement of self-perception and goal setting strategies to improve physical activity were addressed through play and activity themes on this day. A home program was provided to them that they had to follow for the two additional days of the week. Significant improvement was found in the children's body composition (body fat percentage) while, waist- and upper arm-circumferences decreased significantly. A non-significant decrease of 2.9 kg was also found in body weight. The self-perception of the group improved significantly as assessed by the Harter Scale (Kemp & Pienaar, 2010). The compliance to the programme decreased when the supervised part ended, again highlighting the need for professional supervision and sustained motivation of children in obesity treatment regimens. This protocol is now implemented as an obese intervention by Kinderkineticists, with specific adjustments with regard to age appropriateness of the level, selection and inclusion of motor activities and the intensity level of physical activities. The treatment programme can also be used effectively for inactive children by only modifying the intensity of the programme, as it incorporates all the necessary fitness components such as strength and strength endurance, cardiovascular endurance, flexibility and the development of basic motor

The need for the expertise, provided by this discipline in this country with its extreme diversity, not only in population and ethnic groupings, but also in socio-economic status, is substantial. Challenges to bring this service to the deep-rural and remote areas of the country still ask for innovative thinking. A first step in childhood obesity treatment will

children in this country (Kemp et al. 2011, in press).

skills needed for sport participation.

**7.1.2 Implementation**