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Journal of Occupational Therapy, Schools, & Early

Intervention

ISSN: 1941-1243 (Print) 1941-1251 (Online) Journal homepage: http://www.tandfonline.com/loi/wjot20

Occupational Therapy and the Childhood Obesity


Epidemic: Research, Theory and Practice

Michael Pizzi, Kerryellen G. Vroman, Cynthia Lau, Simone V. Gill, Susan


Bazyk, Yolanda Suarez-Balcazar & Susan Orloff

To cite this article: Michael Pizzi, Kerryellen G. Vroman, Cynthia Lau, Simone V. Gill, Susan
Bazyk, Yolanda Suarez-Balcazar & Susan Orloff (2014) Occupational Therapy and the Childhood
Obesity Epidemic: Research, Theory and Practice, Journal of Occupational Therapy, Schools, &
Early Intervention, 7:2, 87-105, DOI: 10.1080/19411243.2014.930605

To link to this article: https://doi.org/10.1080/19411243.2014.930605

Published online: 26 Aug 2014.

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Journal of Occupational Therapy, Schools, & Early Intervention, 7:87–105, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 1941-1243 print / 1941-1251 online
DOI: 10.1080/19411243.2014.930605

Occupational Therapy and the Childhood Obesity


Epidemic: Research, Theory and Practice

MICHAEL PIZZI, PhD, OTR/L, FAOTA,1 KERRYELLEN G.


VROMAN, PhD, OTR/L,2 CYNTHIA LAU, PhD, OTR/L, BCP,3
SIMONE V. GILL, PhD, OTR/L,4 SUSAN BAZYK, PhD, OTR/L,
FAOTA,5 YOLANDA SUAREZ-BALCAZAR, PhD,6
AND SUSAN ORLOFF, OTR/L, FAOTA7
1
Department of Occupational Therapy, Long Island University Brooklyn, New
York, NY
2
Department of Occupational Therapy, University of New Hampshire, Durham,
NH
3
School of Occupational Therapy, Touro University Nevada, Henderson, NV
4
Department of Occupational Therapy, Boston University, Boston, MA
5
Occupational Therapy Program, School of Health Sciences, Cleveland State
University, Cleveland, OH
6
Department of Occupational Therapy, University of Illinois at Chicago,
Chicago, IL
7
Children’s Special Services, LLC, Atlanta, GA

Childhood obesity is a public health epidemic in the United States. Children who are
overweight or obese experience multiple physical, emotional, and social challenges in
daily life activity (occupational) participation. The profession of occupational therapy
addresses children’s current and future health and occupational needs through the abil-
ity to participate in everyday life. Presented in this paper is an overview of the role
occupational therapy can and does play in meeting the challenges posed by childhood
obesity with all children, including those with disabilities. In the context of the research
and prevalence data, examples of occupational therapy interventions for school- and
community-based settings are examined. Case studies illustrate occupational therapists’
contribution in prevention of and intervention for childhood obesity. Future research
and strategies for prevention and health promotion advocating for the occupational
health of children are discussed.

Keywords obesity, childhood, occupation, participation, occupational therapy, health


promotion, quality of life

Introduction
Obesity is a public health crisis faced by America’s children and families. In 2001, the
U.S. Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity
in Americans to date has not been achieved, with no state meeting the 15% adult obesity
Received 3 February 2014; accepted 26 March 2014.
Address correspondence to Michael Pizzi, PhD, OTR/L, FAOTA, Long Island University–
Brooklyn, 1 University Plaza School of Health Professions/Pratt 214, Brooklyn, NY 10022, USA.
E-mail: michael.pizzi@liu.edu
87
88 M. Pizzi et al.

reduction benchmark. This failure is reflected in the continued rise in childhood obesity
(U.S. Centers for Disease Control [CDC], 2011a). Twenty-five percent of children meet the
criteria for being overweight, and the rate of obesity is reaching over 17% of our young
population (CDC, 2011b; Dehghan, Akhtar-Danesh, & Merchant, 2005). The numerous
consequences of childhood obesity are detrimental to the growth and well-being of children.
Costs incurred are deleterious to both children and society. For the child, the consequences
include being bullied, poor school performance, diminished self-esteem, decreased partic-
ipation in healthy social and physical activities, and social isolation (Hayde-Wade et al.,
2005; Puhl, Petersen, & Luedicke, 2013). Long-term costs are seen in the increased inci-
dence of conditions such as diabetes, cardiovascular disorders, joint deterioration, and
mental health problems, and the increased risk mortality in both childhood and/or adult-
hood are well documented (Serdula et al., 1993). This paper discusses the ways in which
occupational therapy practitioners are positioned to take a meaningful and proactive role
within educational, health, and community-based settings to addressing obesity in children.

Overview

Contributory Factors: Diet and Limited Participation in Activities


Primary factors that place children at risk for obesity are nutrition and limited partici-
pation in physical exercise. Many American children have limited access to fresh fruits
and vegetables and spend a substantial amount of time in sedentary activities such as
computer-mediated games and television (CDC, 2011a; Pieper & Whaley, 2011; Raynor,
Jelalian, Vivier, Hart, & Wing, 2009). Considering the emergence of obesity as a com-
mon intermediary for adult health problems and the prevalence of overweight children,
the quality of children’s diet and eating patterns and opportunities to engage in vigor-
ous physical exercises should be addressed in relation to obesity prevention on all levels,
home, school, and the community (CDC, 2011a; Wyatt, Winters, & Dubbert, 2006). For
example, despite initiatives to improve the nutritional quality of school meals, evidence
suggests that children who are eligible for free or reduced fee lunches in public schools
are more likely to be exposed to fried foods and foods with high caloric and high fat
content than children who are not (Suarez-Balcazar et al., 2007). The school environ-
ment further contributes to the weight problem of children as, across the United States,
recess and physical education have been reduced (Fernandes & Sturm, 2010; Floriani &
Kennedy, 2008). Children living in lower-income communities face economic challenges
that are likely to constrain healthy lifestyles as the context of daily life heavily influ-
ences healthy behaviors and occupational participation. Children living in lower-income
communities in metropolitan areas are particularly at risk for childhood obesity (Cahill
& Suarez-Balcazar, 2012). For instance, lower-income communities have one-third the
number of grocery stores of affluent communities (Morland, Wing, Diez Roux, & Poole,
2002). Fast-food chains, convenience stores, and liquor stores are generally more prevalent
in lower-income communities (Morland & Filomena, 2007). Children in these communi-
ties have less access to a variety of fresh and healthy products and fewer opportunities for
outside play due to crime, traffic, and limited green spaces (Evans, 2004; Suarez-Balcazar
et al., 2006; Suarez-Balcazar, et al., 2007). While obesity affects all demographic groups,
African American, Latino, and children with disabilities are identified as high-risk popula-
tions (Suarez-Balcazar, Friesema, & Lukyanova, 2013). Therefore, given the high incidence
of childhood obesity in African American, Latino and low-income communities, educa-
tors, health care practitioners and researchers are focusing their efforts to understand what
Occupational Therapy and Childhood Obesity 89

factors children identify as influencing their health in order to develop and provide effective
preventive and intervention strategies (Fitzgibbon, Stolley, Dyer, Van Hanhorn, & Kaufer
Christoffel, 2002).

Psychosocial and Mental Health Correlates of Childhood Obesity


Obesity in children can be viewed as a dynamic process, one in which behavior, cognition,
and emotional regulation are interrelated and interact (Puder & Munsch, 2010). Primary
concerns and focus of current prevention programs are the adverse health-related corre-
lates of obesity and the psychological and social sequelae that impact children who are
obese. Although the pathways between obesity and mental health problems are ambigu-
ous, children/adolescents who are obese experience high rates of mental health problems
such as shyness and low-self esteem and become victims of bullying (Warschburger,
2005; Zametkin, Zoon, Klein, & Munson, 2004). Many, but not all, experience difficul-
ties with social participation and lower self-esteem (Zametkin et al., 2004). Impulsivity and
attention-deficit hyperactivity disorder, depression, and anxiety as well as behavioral eating
problems are associated with obesity. Lower self-esteem is more prevalent among children
who believe that they are responsible for their overweight and those who think that being
overweight interferes with their social relationships and ability to attract friends (Pierce
& Wardle, 1997). A significant relationship exists between dissatisfaction with physical
appearance (poor body image) associated with obesity and psychosocial problems (poor
psychological function, depression, and binge eating) particularly among girls (Herbozo
& Thompson, 2009). Poor psychological well-being additionally contributes to lower lev-
els of participation in physical activities. Children who are obese report that they enjoy
sports less, especially high-energy activities such as running. In summary, the interaction
between obesity and psychological problems has two sequelae: clinically significant psy-
chological disorders that may be associated with obesity or may contribute to weight gain
and psychosocial problems related to successful participation with peers (Puder & Munsch,
2010).

Stigma, Discrimination, Social Exclusion, and Quality of Life


Body size is the most stigmatizing physical characteristic after race (Herbozo & Thompson,
2009). Obesity is the antithesis of the Western ideal of physical attractiveness. Individuals
who are obese are subject to weight bias and stereotyped weight-related attitudes and
beliefs. Such attitudes typically result in rejection or prejudice including being teased,
socially excluded, or even physically and/or emotionally bullied (Puhl & Later, 2007).
Stereotyping associated with people who are obese include laziness, self-indulgence, unre-
liability, untrustworthiness, and lacking of self-discipline. Children as young as 3 years
old have been found to stereotype children who are obese as “ugly,” “stupid,” and “dirty”
(Haines & Neumark-Sztainer, 2009). These negative attitudes are also prevalent among
education and health care professionals. In a study examining perceptions about disabili-
ties, occupational therapy students ranked obesity as one of the hardest disabilities to live
with, while in another study, occupational therapy students exhibited prejudicial attitudes
to obese clients (Delin, 1995; Vroman & Cote, 2011). Similarly, one-fifth of high school
teachers and health care workers stated that they thought obese persons were more emo-
tional, less tidy, and less likely to succeed at work and had personalities different from
those of people who are not obese (Neumark-Sztainer, Story, & Harris, 1999). We can only
assume that these prejudicial attitudes are also applied to children who are obese.
90 M. Pizzi et al.

These prejudicial attitudes are definitely expressed by children. Children who are obese
experience teasing and are socially excluded by their peers (Warschburger, 2005; Zametkin
et al., 2004). Associated with the painful experiences of being teased or bullied, these
children also experience negative psychological, attitudinal, and behavioral outcomes. For
example, children who experience weight-related criticism are likely to have negative atti-
tudes toward sports and engage less in physical activities (Faith, Leone, Ayers, Moonseong,
& Pietrobelli, 2002). Some studies found that adolescents who reported weight-related
teasing were more likely to engage in dysfunctional patterns of weight control (smok-
ing, purging, using laxatives and diuretics, and fasting) than did their peers (Haines &
Neumark-Sztainer, 2006). Those children who are severely obese are most vulnerable and
are reported to have quality-of-life ratings comparable with children who have cancer (Puhl,
2013). Health and education practitioners including occupational therapy practitioners need
to be cognizant of the pervasiveness of prejudicial anti-fat attitudes toward obese or over-
weight children that could lead to marginalization and victimization. It is imperative that
the issue of stigma and marginalization be addressed on multiple levels that include equip-
ping children with strategies to be assertive and negate bullies and through education to
reduce the stigma of obesity.

Health Promotion and Obesity Prevention and Intervention in the School


Setting

Efficacy of Interventions for Childhood Obesity in the School Setting


Schools are a popular and convenient setting for obesity prevention and intervention pro-
grams for a diverse group of children. However, the growing body of empirical research
examining the effectiveness of childhood obesity prevention and intervention school-based
programs reveals there is no single model that fits the needs of all schools and student
populations (Khambalia, Dickinson, Hardy, Gill, & Baur, 2011, Johnston, Moreno, El-
Mubasher, Gallagher, Tyler, & Woehler, 2013). Programs described in studies examining
the effectiveness of school-based prevention and interventions programs show they are gen-
erally heterogeneous in their design, target populations, the approaches used to reduce
obesity, and the outcomes attained and the length of interventions varies from weeks to
months (Coleman et al., 2005; Gutin, Yin, Johnson, & Barbeau, 2008; Khambalia et al.,
2011; Summerbell, Water, Edmunds, Sam, Brown, & Campbell, 2005). A randomized con-
trolled trial study found an intensive lifestyle intervention (in the last period of the school
day) with foci on nutrition and activity was effective at reducing Body Mass Index (BMI)
in children between the ages of 10 and 14 years after 6 months (Johnston, Tyler, McFarlin,
Poston, Haddock, & Reeves, 2007). Similarly, a 2-year study of the Coordinated Approach
to Child Health program for children between third and fifth grades that entailed increasing
physical activity in school, changing the cafeteria food, and classroom curriculum on health
and nutrition found the weight increase of the children in the four intervention schools with
the program was less than children in the four control schools, but programs did not prevent
the slow weight gain of the children (Coleman, et al., 2005; Heath & Coleman, 2003). A
school-based intervention entitled Wellness, Academics & You implemented by teachers in
69 classes of fourth and fifth graders over 6 months had positive shifts in BMI, increased
consumption of fruits and vegetables, and an increase of physical activity levels among
its notable outcomes (Spiegel & Foulk, 2006). Another after-school physical activity inter-
vention led to a decreased percent of body fat in 9- to 11-year-olds (Gutin et al., 2008).
The gaps in the current literature on the school-based interventions are the lack of data on
Occupational Therapy and Childhood Obesity 91

intervention efficacy for children below the age of 9, heterogeneous groups of children, or
children from low-income families (Stephens, 2005; Story et al., 2003).
An earlier systematic review of school-based obesity prevention programs reported
that the programs that were successful at reducing BMI were not implemented by the
classroom teachers but implemented by staff employed and trained outside the hosting
school (Baranowski et al., 2002). It is challenging for educators to implement programs
with the competing demands in the classroom, especially given the pressure of meeting
academic benchmarks.
Overall, the conclusion drawn in many of the systematic reviews of interventions and
prevention programs for obesity in children indicated there is not enough evidence to
support any one particular program, although comprehensive strategies directed toward
dietary and physical activity change, together with psychosocial support and environ-
mental change, may prevent obesity (Khambalia et al., 2011; Safron, Cislak, Gaspar, &
Luszczynska, 2011; Summerbell et al., 2005). Furthermore, the outcome of school-based
programs, even after being in place for several decades, remains mixed. Innovation is
needed to develop an effective obesity prevention program that (1) targets all elementary
aged children including younger children, (2) will not overburden the existing school cur-
riculum, (3) will provide psychosocial support to children to build self-efficacy related to
healthy living habits within the context of each child’s routines and environments, and
(4) and facilitates ongoing collaborative efforts among government agencies and nonprofit
organizations to promote health and community service. Innovation is especially needed
for children living in lower socio-economic status (SES) areas because these children are
at even higher risk than the general population for obesity due to the lack of opportunity
for physical activity and lack of access to healthy foods (Cahill & Suarez-Balcazar, 2009;
Wang, 2001).

Childhood Obesity and the Role of Occupational Therapy


A public health approach to the physical and mental health of all children and youth is one
model by which occupational therapy practitioners serve children who are overweight or
obese and their families . For example, Bazyk and Arbesman (2013) describe a multi-tiered
public health approach to addressing the mental health issues surrounding obesity in chil-
dren and youth. A public health, multi-tiered model means considering how occupational
therapy services foster occupational performance at the universal (tier 1), targeted (tier 2),
and intensive (tier 3) levels. Evidence to support occupation-based services at each tier have
been described (Bazyk & Arbesman, 2013).
At the universal level, promotion of physical and emotional health focusing on optimiz-
ing health and building competencies in all children is emphasized. Examples are to build
strengths and design environments to help children thrive and be healthy (Barry & Jenkins,
2007; Bazyk, 2011). In terms of obesity, recent efforts specifically emphasize making health
a primary motivator for helping children develop positive lifestyle behaviors rather than just
focusing on weight loss in those who are already overweight. The Surgeon General’s Call
To Action To Prevent and Decrease Overweight and Obesity indicates that one of the prior-
ities should be to change attitudes about overweight and obesity at all ages—shifting from
an emphasis on appearance to one of health and well-being (U.S. Department of Health and
Human Services, 2001). Occupational therapy practitioners can also teach children how to
navigate their own environments. An example of that may include building strategies for
taking a route to school that avoids walking by a fast food restaurant.
92 M. Pizzi et al.

Occupational therapy practitioners working at the universal level can contribute to


school-wide efforts that promote health in children of all weights (Weight Realities Division
of the Society for Nutrition Education, 2003). They work with health care, school, or com-
munity teams to teach children to make healthy food choices during snacks and meals
and making sure healthy foods are available in vending machines and during snacks.
Occupational therapy practitioners can make sure enjoyable physical activities are available
during recess and after school. These include some non-competitive sports programs and a
wide range of physical leisure activities such as a walking club or hiking club. Successful
examples on occupational therapy initiatives on this level include a collaboration among
the occupational therapy faculty and students at the University of Illinois and the staff at a
public school. They established a Healthy Lifestyle Initiative (Cahill, Daniel, Nelson-Stitt,
Brager, Dostal, & Hirter, 2009). This 2-year initiative focused on increasing aerobic activ-
ity, limiting sedentary activities, and increasing healthy eating within the school curriculum
and community. One of the activities that the occupational therapy students participated in
was teaching the children about the activity pyramid and how they could participate in activ-
ities that would increase their flexibility, strength, and aerobic activity levels. In another
program, occupational therapy students, under the guidance of faculty at the University
of South Dakota, successfully started an after-school obesity prevention program for ele-
mentary aged children using running-based activities (Smallfield & Anderson, 2009). The
activities were successful because the children chose them and considered them fun and
meaningful. The faculty and students at Touro University Nevada have established an
ongoing service-learning program, Healthy Choices for Me, that provides health promo-
tion activities to children from lower socioeconomic schools in an after-school program
(Lau, 2011). The elementary-age children participate in physical activities, nutrition educa-
tion, light meal preparation, and self-efficacy development regarding daily healthy choices.
An efficacy study showed that the children at risk who participated in the Healthy Choices
for Me program improved their self-efficacy in regard to healthy food choices and were
eating a wider variety of vegetables by the end of the program (Lau, Stevens, & Jia, 2013).
Another important component at the universal level is ensuring and/or developing
school-based education about weight bias for all students and adults. A critical dimension
of such education is the implementation of policies that prohibit weight-based bullying.
Children may face weight bias from multiple sources including peers, teacher, health care
providers, and even parents. They may encounter verbal teasing (name calling, derogatory
remarks), social exclusion (being ignored), and physical bullying (pushed, shoved). About
one-third of overweight girls and one-fourth of overweight boys report being teased by
peers at school, and those who are victimized are more vulnerable to depression, anxiety,
lower self-esteem, and poor body image (Puhl & Later, 2007). With this awareness, child-
hood obesity prevention programs in schools and community settings to promote health
in overweight and obese children must simultaneously protect them in the face of social
stigmatization and its consequences.
Last, it is important for occupational therapy practitioners to think about the kind of
messages that the school is providing about obesity and consider whether they may, in fact,
be harmful and undermine the children they are aiming to help. For example, negatively
focused health messages (e.g., that emphasize the undesirability of being overweight) may
lead students to feel worse about themselves. Professionals must carefully consider how
prevention messages are framed in order to avoid the potential psychosocial (e.g., poor
self-esteem) and physical health (e.g., binge dieting) consequences that can result (Bazyk
& Winne, 2013; Puhl & Later, 2007).
Occupational Therapy and Childhood Obesity 93

At the level of targeted services, the focus is more specifically on the prevention of
obesity. At this level, it is important for occupational therapy practitioners to be aware of
the conditions that place children at risk for becoming overweight and embed strategies to
prevent obesity.
Low-income children in general tend to be at higher risk for obesity. Many of these
children are children from minority backgrounds. Also, two groups of children who are at
greater risk of obesity are those living in poverty and those with disabilities. Youth grow-
ing up in low-income urban environments in working-class African-American and Latino
communities demonstrate rates of obesity almost double as compared to White children for
several reasons (Cahill & Suarez-Balcazar, 2009). First, their environments generally pro-
vide fewer opportunities for physical activity (e.g., fewer safe public play areas) and less
access to nutritional foods (prevalence of fast food outlets and convenience stores versus
grocery stores).
Children with developmental disabilities tend to become overweight at a rate of 40%
greater than the general population. This often leads to a greater number of obesity-related
secondary conditions (e.g., fatigue, pain, deconditioning, social isolation, difficulty per-
forming activities of daily living; De, Small, & Baur, 2008; Rimmer, Rowland, & Yamaki,
2007). A number of factors may contribute to their tendency to become overweight includ-
ing the coexistence of certain genetic syndromes known to be associated with obesity
(Prader-Willi), reduced levels of physical activity, and the use of medications that can
cause weight gain (De et al., 2008; Rimmer, Yamake, Davis Lowry, Wang, & Vogel, 2010).
Factors within the physical and social environments may also contribute to a lack of phys-
ical activity such as a lack of access to recreation facilities and limited knowledge among
staff on how to adapt programs for youth with disabilities (Rimmer et al., 2007). Finally,
studies have shown that by 3 years of age, children with developmental delay are signifi-
cantly more likely to be obese than their typically developing peers (Emerson, 2009). Such
findings make a case for the investment in interventions during the early years of life to
prevent the emergence of obesity among children with developmental delay (Bazyk, 2011).
It is important for occupational therapy practitioners to be aware of conditions that put chil-
dren at greater risk of obesity and embed strategies to prevent obesity and promote health
into their interventions (Bazyk & Winne, 2013).
Targeted intervention should start early by embedding prevention strategies in early
intervention and preschool programming. Small-group after-school clubs that emphasize
nutrition and physical and mental health activities can be effective (e.g., walking clubs,
healthy cooking clubs, jump rope groups).
At tier 3, services focus on children and youth who are already overweight or obese.
At this level, it is important for occupational therapy intervention to focus on both the
physical and emotional causes and consequences of obesity (Bazyk & Winne, 2013). For
example, children who are overweight may experience fatigue and difficulty performing
physical activity. Occupational therapists need to grade gradual participation in physical
activities. The occupational therapy practitioner may want to systematically introduce chil-
dren to a range of physical activities and help them identify what kinds of activities they
enjoy the most. An occupational justice approach would include helping create frequent
opportunities to participate in such activities.
Emotionally, children who are overweight may struggle with depression and/or low
self-esteem. It is important that occupational therapy practitioners also embed strategies
that allow children to express their feelings and develop an awareness of their individ-
ual character strengths—sense of humor, creativity, being kind. The use of small-group
interventions may be particularly helpful at both tiers 2 and 3 (Bazyk & Winne, 2013).
94 M. Pizzi et al.

Supporting Children’s Occupations in the Face of Childhood Obesity


Much of the literature on childhood obesity discusses the influence of obesity on chil-
dren’s physical (Gill, 2011; Gill & Hung, 2012; Hills & Parker, 1991; Wearing, Hennig,
Byrne, Steele, & Hills, 2006), physiological (D’Onise, Lynch, & McDermott, 2012; Park,
Falconer, Viner, & Kinra, 2012), and psychological well-being (Harriger & Thompson,
2012; Russell-Mayhew, McVey, Bardick, & Ireland, 2012). However, living with obesity
entails more than focusing on weight loss. Obesity management for children involves
addressing how obesity affects their occupations. Children need support in family, play,
and school settings to lead healthy, active lives. Calls for children to eat healthy meals and
to engage in more physical activity are intertwined with their occupations in their family
lives, play experiences, and school environments.

Eating Habits
The lives of adults living with obesity is quite different than the lives of children who are
obese. Most adults have autonomy over their daily routines, but children are largely insepa-
rable from their families’ established routines, habits, and schedules (Levin & Kirby, 2012).
For example, at home, most adults have the power to structure their meals to incorporate
healthy options and to control portion sizes. In contrast, most children must rely on their
parents’ efforts to prepare healthy meals and to serve appropriate portions. Therefore, chil-
dren who are obese or overweight have the increased challenge of living healthy lives in the
context of their families’ already existing regimens that may be unhealthy. Consequences
of this may be having diminished power and control in decision making related to family
routine.
Some of the difficulty with eating healthily among families is associated with par-
ents’ work schedules. For example, working during non-traditional times (i.e., evenings
or weekends) is linked with children who are overweight or obese for both mothers
(Anderson, Butcher, & Levine, 2003; Brown, Broom, Nicholson, & Bittman, 2010) and
fathers (Champion, Rumbold, Steele, Giles, Davies, & Moore, 2012). Busy work schedules
that conflict with the amount of time that families spend together make it challenging for
parents to serve meals to children at regular times (Anderson, 2012), to eat meals together,
and to decrease the amount of time that children are unsupervised to eat unhealthily (Lehto,
Ray, & Roos, 2012).
The challenge for children to eat healthy meals is not only relegated to their home envi-
ronments. During the week, children spend most of their waking hours in school. In schools,
food choices create challenges for children living with obesity. School cafeterias offer food
options for children that are not always healthy. Consequently, the availability of unhealthy
foods in school cafeterias is linked with higher body mass index scores (Fox, Dodd, Wilson,
& Gleason, 2009); children are surrounded by myriad unhealthy foods including beverages
high in sugar content. For example, schools that provide foods low in nutrients and dense
in energy (e.g., French fries or desserts) have more children with body mass index scores in
the obese range (Fox et al., 2009). This makes it difficult when healthy foods are limited in
availability or are positioned amid unhealthy foods that seem more appetizing to children.

Physical Activity
Children’s lack of physical activity is influenced by parents’ schedules and limited oppor-
tunities to engage in play activities. In some households, parents’ busy work schedules
Occupational Therapy and Childhood Obesity 95

affect the amount of physical activity that families engage in during their time together
(Bauer et al., 2011). Although parents are aware of the importance of increasing physi-
cal activity, the logistics of incorporating activity into their families’ lives is viewed as a
barrier and leads to decreased physical activity (Thompson et al., 2010). It is clear that chil-
dren’s decreased caloric intake and increased energy expenditure lead to weight loss and
increased metabolic health. However, when the family is taken into account, the situation
is even more complex than simply decreasing calories and increasing activity. Indirect
effects on children’s health status linked to the family include parents’ own eating habits
and amounts of physical activity; parents with healthy eating habits and regular bouts of
physical activity have children with lower body mass index scores (Hendrie, Coveney, &
Cox, 2011). Therefore, parents’ behaviors indirectly influence their children’s health by
affecting how they structure the home environment via availability of fruits and vegetables
(Fisher, Mitchell, Smiciklas-Wright, & Birch, 2002; Hingle et al., 2010) and by role mod-
eling healthy eating and engagement in physical activity (Bogaert, Steinbeck, Baur, Brock,
& Bermingham, 2003).
Play, a central part of children’s occupations, can contribute to increased physical
activity. However, opportunities for play are limited by high amounts of sedentary activity.
Obesity for children has been linked to increased amounts of time spent watching televi-
sion (Hingle & Kunkel, 2012) and playing video games (Francis, Stancel, Sernulka-George,
Broffitt, Levy, & Janz, 2011). It is difficult to disentangle whether sedentary activities lead
to obesity or whether children who are obese choose sedentary activities because of poor
body image (Harriger & Thompson, 2012) or low feelings of self-efficacy (Guinhouya,
2012). In either case, limited time spent playing is associated with increased body mass
index scores (Burdette & Whitaker, 2005).
Although a pragmatic approach to sedentary behavior involves encouraging decreased
sedentary behaviors and increased play outdoors, not all children have opportunities to
engage in play. For some children, unsafe neighborhoods or neighborhoods lacking in avail-
able playground equipment limit opportunities to play outdoors (Kimbro, Brooks-Gunn, &
McLanahan, 2011). Socioeconomic status is tightly coupled with neighborhood safety and
resources as well as amounts of unstructured time for children; children from low socioe-
conomic backgrounds tend to live in less safe neighborhoods with fewer resources (Leslie,
Cerin, & Kremer, 2010). Those same children have more unstructured time but spend that
time engaging in sedentary activities (Kimbro et al., 2011). Given these pressing concerns,
a need to encourage play has been earmarked as an opportunity for health promotion for
children living with obesity (Alexander, Frohlich, & Fusco, 2014).
Occupational therapists can help families and children to put routines into place that
support good nutrition, increase graded physical activity, and promote positive self-esteem
at home and at school. Therapists can help families to create a home environment that
encourages a schedule for eating family meals together, to engage in physical activity
together, and to offer encouragement by focusing on successful changes to habits and
routines that the children adopt. For example, a family calendar put together by families
can include select days and times when the family as a whole commits to eating together,
engages in physical activity together, and highlights family successes. In the school envi-
ronment, occupational therapists can help children to plan making healthy food choices in
school by selecting foods prior to getting onto the cafeteria line.
Play is a major occupation of children. Occupational therapists can also help chil-
dren incorporate play into their everyday lives. Suggesting structured classes available for
children can help to increase physical activity by incorporating play activities. Organizing
unstructured play opportunities for children can also be part of an occupational thera-
pist’s role in supporting a safe play environment for children. Therapists can also suggest
96 M. Pizzi et al.

working physical activity into children’s and families’ routines even if they are not play
activities. For example, therapists can organize a “walking school bus” so that children par-
ticipate in a low-cost, supervised physical activity while walking to school (Kong, Sussman,
Negrete, Patterson, Mittleman, & Hough, 2009; Larouche, Laurencelle, Shephard, &
Trudeau, 2011). Occupational therapy practitioners can work with school teachers on how
to incorporate play activities in which all can participate.
In sum, the role of occupational therapists in obesity management involves focusing
on the effects of obesity on children’s central occupations in their families, while playing,
and in school. Occupational therapists can capitalize on their unique ability to use client-
centered, occupation-based intervention to support prevention and health promotion so that
children can perform occupations central to their everyday lives.

School-Based Case Study


Mary is an 8-year-old Caucasian third grader in a suburban public school. She is an only
child and lives in an upper-middle-class nuclear family with both parents. Although she had
tested well within above-average range of abilities, nonetheless she was challenged aca-
demically. Although there seemed to be many contributing factors, a major one appeared
to be her body size. While not being morbidly obese, Mary was extremely overweight and
consequently moved more slowly than her peers, had trouble engaging in activities that
required movement, and was often excluded from play activities. She was the last to get off
the school bus, which, at times, made her almost late for getting into class before the bell,
creating cognitive and temporal disorganization. She was often late finishing class work,
had few friends, and demonstrated poor interaction with peers in general. Most concerning
was that Mary was not only isolated from her peers, she also tended to isolate herself. She
would choose to eat lunch alone. Mary did not interact on the playground during recess,
preferring to hang by the fence alone until the bell was called to come in. In addition, the
teachers had noted that there were subtle negative comments made to her that could be char-
acterized as bullying. Understandably, Mary’s response more often than not was to lash out
in anger at the offending peer, resulting in further bullying. The school counselor was trying
to figure out a situation that would address Mary’s physical and emotional health and con-
sulted with the occupational therapist after having exhausted the traditional interventional
routes such as time with the counselor, resource help, and even a “friends group” run by
the speech therapist.
Occupational therapy is ideally suited to be the conduit for such situations.
Occupational therapy practitioners are trained to evaluate the entire person: physical, emo-
tional, neurological, andsocial. Obviously, Mary was having issues in all four realms.
Although it appeared obvious that if Mary was less of a standout as “the fattest kid in
the class,” as her peers often referred her to, things would be better for her. However, the
occupational therapy goal was not to get her into a weight loss program but to help her
improve her quality of life and levels of participation in daily occupation.
Occupational therapy works across the spectrum of life management, so the primary
goal was to promote and have Mary adopt a healthy lifestyle. Creating the setting for this
was within the scope of activities of daily living, an occupational therapy area of expertise.

Occupational Therapy and a Team Approach


The counselor and occupational therapy practitioner came up with a Lunch Bunch club
idea. Children in this group were not all obese, but all did have some social issues, such
Occupational Therapy and Childhood Obesity 97

as anger management. Initially, the counselor and OT team planned activities that were
thought enjoyable for the children. Lunch was “served” in the counselor’s office, and
healthy lunch selections were provided. Topics for discussion in the Lunch Bunch were
proposed and led by the children. This gave more meaning to the students as a group and
facilitated greater participation.
Since most of the children were not “recess stars” (children who achieved motorically
or were the “popular kids”), the counselor and occupational therapy practitioner tried a few
activities that were thought to be enjoyable. This happened in a corner of the play/recess
area. Frisbee was attempted, but the children felt too exposed so, after one or two times,
that was discontinued. The children came up with the idea of a “Walking Club.” Restricted
to the gated school grounds, permission was granted from the principal to go outside the
area and walk the block around the school.
Other kids noticed and wanted to know why “those kids got to go out and they didn’t.”
Suggestions were made from classroom teachers on ways to expand the group to new
“members.” Walking Club became a place where kids ate with a small group that was
more private than the cafeteria. The Walking Club, begun by this initial group of students
needing special attention and help, became the desirable club to join. Wanting to make the
program inclusive, a local independent sports store was approached to donate pedometers.
This was also a way to make the community aware of the goals that were more than purely
academic. A small community newspaper picked up on it and provided a short “blurb”
in their bimonthly publication. The Parent-Teacher Organization (PTO) was approached
and helped to buy pedometers for the classrooms. The physical education (PE) teacher got
involved to help put variety into the walks.
This collaboration using the occupational therapist, school counselor, PE teacher, PTO,
and the community at large and eventually making it open to all kids was a way of making
Mary a participant and not the focus of the group. In addition, bus monitors were desig-
nated to be the last one off the bus and checked to make sure book-bags, sweaters, and
assorted other items were not left behind. This became a prestige position. Mary was made
bus monitor for her bus. She was no longer rushing and getting into class in a panic. Her
occupational role as bus monitor included stopping at the office to drop off items or to
report that the bus was “all clear.”
Over time, Mary’s self-esteem rose considerably as noted by her increased participa-
tion and social interactions with others. Some (not all) children in her class began to see her
as a participant and not as that “other kid.” Teachers reported that verbal bullying had vir-
tually stopped. With the whole school involved, competition for the most steps walked by
any given class in a given month evolved. The class with the most recorded steps got their
picture in the main hallway and a ribbon they could wear for the whole month. To make it
fair, no class could win 2 months in a row.

Why This Worked


This program promoted inclusive participation not just for a few children but was open
to the whole school. There was community and PTO involvement, and the initial children
who originated the program, including Mary, were given “special status.” However, by
including the whole school, they were also made to feel integrated into the larger group.
The art and science of occupational therapy were fully evidenced through the development
of this program. The primary goal of health and life enhancement, improving quality of life
and increasing occupational participation for one child with a weight management issue,
evolved into a population-specific intervention that promoted the health of an entire school
98 M. Pizzi et al.

by creating normalized environments that promote health as a way to be, not as a short-term
program of limited scope, such as a “diet.” It is within the scope of practice of occupational
therapy to address the individual and community needs and blend them seamlessly to create
healthy and successful living.

Early Intervention Case Study


José was a 24-month-old with Prader Willi seen by occupational therapy as part of
an interdisciplinary early intervention team. The occupational therapist worked with a
developmental specialist, a nutritionist, and the family during biweekly home visits. José’s
low tone and excessive weight affected his gross-motor skills. He was delayed in all motor
milestones and only recently began to walk independently. His low muscle tone and delayed
motor skills also impacted his participation in age-appropriate play and self-help activities.
He had difficulty moving from supine to sit to for upright sitting activities. While in sitting,
José demonstrated poor bilateral protective reactions and was unable to regain balance dur-
ing reaching activities. As a result of his delayed postural reactions, he found it difficult to
reach beyond midline for toys and manipulating toys with both hands without falling over.
As for self-feeding skills, José had difficulty using a spoon, and drinking from a cup and
stuffed his mouth, demonstrating some hoarding behaviors during meals.
José was the first grandchild of his family, and his parents, at the time, were still in
high school. He was taken care of by his grandparents during school hours and by his
parents after school. The parents and grandparents tended to reward him with unhealthy
foods such as Cheetos. His parents would give him snacks as rewards when José attempted
to pull to stand at furniture or maintained sitting balance for an extended period of time.
In addition, José’s family would give him food as rewards when he attempted to imitate or
verbalize sounds to make his needs known. In addition, food was available throughout the
day at home. José also drank liquids such as milk, juice, and even soda from a bottle. José
enjoyed all foods, but mac and cheese was his favorite. His regular diet consisted of waffles,
pop tarts, sausage, pizza, happy meals, and Lunchables. His parents would routinely buy
low nutritional food from the local gas station after school to share with family members
when arriving home.
Intervention was primarily home-based care and focused on family’s goals, behaviors,
and habits. It was important to have ongoing discussions with the entire family consisting
of the grandparents and parents to ensure that all the members were in agreement of family
priorities and specific routine-based intervention strategies. The grandparents and parents
were concerned about José’s increasing weight because he was not always motivated to
walk, and it became increasingly difficult for him to be carried. Team strategies with the
family centered on diet, eating habits, and improving age-appropriate developmental skills
including self-feeding. Children with Prader Willi tend to move less and burn less calories;
therefore, they require fewer calories. Low muscle tone may also impact intraoral awareness
of food and oral motor skills for eating. As a result, José had difficulty chewing and forming
a bolus of food to swallow, and he stuffed his mouth when eating. His quick pace during
mealtime manifested into food hoarding behaviors.
The nutritionist working with José was promoting a healthy weight for his age and
educating the parents and grandparents about the impact of food on his diagnosis. She
coached the entire family on healthy meal options that were still easy for them to provide
to José, reading nutrition labels, and avoiding empty calories such as soda. She also wanted
food to be only part of meals and not used to reward him throughout the day. In addition,
the nutritionist collaborated with the family in identifying nutritious and low-calorie foods
Occupational Therapy and Childhood Obesity 99

that were culturally acceptable to them. She also provided them with recipes that were easy
to prepare in a short amount of time and with minimal ingredients.
The occupational therapist collaborated with the family in establishing mealtime rou-
tines that involved specific times of the day, eating together, eating with focus and without
the TV on, and using a child-size chair to increase José’s stability while sitting at the
table. The occupational therapist also worked directly with José to promote his oral sen-
sory awareness and pacing during meal time at home. This included “wake up” activities
for his mouth before and during meal time. Also, environmental modifications were used
to promote a slower pace when eating. For example, containers to slow his pace during
snacks were used, and a mirror to provide visual cues for when his mouth was empty and
he was ready for another bite. These strategies were demonstrated to José’s parents, and
they practiced them with the occupational therapist. A play-based physical activity routine
within the family’s daily schedule was also created to promote strength and endurance and
burn additional calories. The family physical activity time was set in between the hours of
3 and 4 every day when they had a choice of taking a walk in the neighborhood, playing at
the jungle gym at the park, moving to a kids’ exercise video, or dancing to music. Based
on the weather, it was important to have both outdoor and indoor activities available year
around for José. In addition, José participated in a weekly play group implemented by the
occupational therapist along with the developmental specialist at the local recreational cen-
ter. Both typically developing and children with medical diagnoses attended this inclusive
play group. The goal of the group was to improve social skills, motor skills, self-feeding
with utensils, and drinking from an open cup. These are all skills the children needed to suc-
cessfully transition to an early childhood special education program or general preschool
program. The parents received peer emotional support and shared strategies from other
families attending the group.
Since food is a large part of the cultural heritage of José’s family, the family found it
difficult to deny José food as a reward. Respecting the family’s culture, it was important
to not completely take away all desirable food but to make the focus of food during struc-
tured meal times and healthy amounts rather than being available throughout the day. The
occupational therapy practitioner teamed with the family to brainstorm additional options
for non-food rewards such as stickers, bubbles, favorite toys, or praise. José was just as
motivated to participate in challenging motor and self-help activities when given praise
and/or access to his favorite musical books. The entire family was responsive to the posi-
tive changes in José and recognized the importance of establishing positive healthy routines
for all the family members as José continues to develop and prepares to transition to early
childhood education.

Conclusion
Occupation is essential in daily life to promote health and well-being, and being limited
by a preventable health challenge can be devastating emotionally, physically, socially, and
mentally to children and their loved ones. This article examines the powerful influence of
obesity and being overweight as it affects daily life and participation in daily occupations of
children and youth and the role of occupational therapy. Occupational therapy, as evidenced
in this article, can be a major influence in the prevention and remediation of childhood
obesity and on the occupational lives of children and their families impacted by obesity
and being overweight. The approach taken by occupational therapy practitioners to this
health issue is holistic in nature. Occupational therapists view children as dynamic and
ever changing who constantly interact with environmental influences. The pandemic of
100 M. Pizzi et al.

childhood obesity requires individual, community, and population-based interventions that


are multidimensional in scope.
The American Occupational Therapy Association (AOTA) workgroups on obesity
and school-based practice have developed a number of resources for occupational therapy
practitioners, other health professional, families and children. Among these is a fact sheet
related to childhood obesity and the role of occupational therapy (http://www.aota.org/∼/
media/Corporate/Files/Practice/Children/SchoolMHToolkit/Childhood%20Obesity.ashx).
These resources can be obtained from http://www.aota.org.
It is crucial, given the health and social consequence of childhood obesity, that occu-
pational therapy practitioners advocate for occupational therapy services to be an integral
component of the interprofessional team addressing childhood obesity. It is incumbent upon
us, as occupational therapy practitioners serve children and their families. These marginal-
ized children need our professional care and require us to be contributing health care team
members for their lives, their health, and their well-being.

Note
The AOTA Obesity Workgroup, chaired by Sandra Schefkind, first presented the con-
tent of this article as a short course at the American Occupational Therapy Association
Conference, 2012.

Acknowledgement
The authors wish to acknowledge Sandra Schefkind’s leadership of this working group and
other members who, although not represented in the authorship, contributed ideas to the
development of this article.

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