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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
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.
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
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).
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.
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).
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.
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.
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.
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.
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.
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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