CLINICAL PERSPECTIVES
Rules of Thumb: Three Simple Ideas for Overcoming the Complex Problem of Childhood Obesity Kristopher Kaliebe,
C
hildhood obesity correlates with increased internalizing disorders, externalizing disorders, attention-deficit/hyperactivity disorder, learning disorders, and academic underperformance.1 However, families rarely present to mental health practitioners to treat obesity directly, and minimal guidance exists regarding how to address this multifaceted problem during a time-limited office visit. Moreover, many behavior patterns associated with obesity, such as sedentary lifestyles, excessive media exposure, and inappropriate diets, also correlate with psychiatric diagnosis or psychological distress.2 Thus, clinicians may want to consider an approach that focuses on educating parents or other caregivers about some common factors driving these harmful modern lifestyles. The following method emphasizes to caregivers 3 simple family-oriented goals (authoritatively labeled “rules”) to assist navigating a complex, ever-evolving world that is often averse to healthy behaviors. The “rules” aim to lead caregivers toward decisions that promote physical health and mental health and are suitable as part of treatment and prevention (for a sample handout for caregivers, see Supplement 1, available online). This approach makes use of heuristics, or mental shortcuts, such as “rules of thumb.” Heuristics are a set of learned or hardwired internal cognitive biases that drive a surprisingly large amount of human choices.3 They have the advantage of being straightforward and practical, although imperfect, decision-making tools. Innate heuristics make us irrational in certain ways, including being susceptible to manipulation by
Supplemental material cited in this article is available online.
MD
marketers. However, applying judicious heuristics can effectively facilitate healthy choices, especially in challenging risk-opaque environments. Thus 3 simple “rules,” if rightly appreciated, can powerfully influence numerous prudent choices. How clinicians conceptualize problems guides their communications and treatments. The overconsumption of highly palatable caloric foods links the problem of obesity with other contemporary “overuse” challenges our children and adolescents face, such as excessive involvement with electronics. For example, “media hyper-reality” difficulties include problematic television viewing, video game play, or preoccupation with telephones or social networking. Other similar hyper-sensory modern enticements are gambling and substance abuse. All these pleasurable or engaging activities stimulate the brain’s “get more” drive. When these behavioral cycles become strengthened through habit, over time it can compromise health and functioning. This coherent story, albeit oversimplified, about how children and adolescents are at risk of these many modern temptations gives caretakers an opportunity to appreciate why several types of limit setting are critical and that these overuse problems are frequently interrelated. This wide-ranging caution can help parents better understand the world they are caught up in and allows flexibility as new challenges emerge. Regarding the framing of risks associated with sedentary modern lifestyles, a thought-provoking adage is that “birds fly, fish swim, and humans walk (or run).” Viewed in this context, it is absurd for humans, especially children, to sit for much of the day and not spend significant amounts of time moving around. The negative consequences of excessive sitting and infrequent
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 4 APRIL 2014
www.jaacap.org
385
KALIEBE
walking are profound but under-recognized. This is perhaps due to the cognitive dissonance created by the human desire for comfort and energy conservation in a world filled with couches, chairs, and mechanical transportation. This statement can help illuminate the significance of the rule “get up and move,” which speaks to avoiding excessive sitting and that frequent movement is critical for health. Furthermore, as mentioned earlier, decision making can be compromised by the enormous complexity of modern environments. Such seems the case with the dilemma of what to eat in a world replete with highly palatable food choices but often lacking in customs, standards, and traditions. Food’s ubiquitous and complex role in human health also overwhelms the common scientific approach of researching individual components, ascertaining their function, and piecing the parts together to understand the whole. There is much we do not know about modern diets, yet it is clear they lead to poor health outcomes. As a method to select what to eat, the idea of monitoring various nutrients seems attractive and is popular. However, this technique has significant limitations and, in fact, is incapable of making a simple determination of whether modern whole wheat bread (containing xanthum gum, sodium stearyl lactylate, and high fructose corn syrup) is, in fact, “healthy.” In addition, agonizing over the minutiae can lead to overvaluing certain ingredients or nutrients and disregarding the rest. This scheme also requires significant cognitive effort and is easily manipulated by marketers. Importantly, heuristics can be protective in many ways. The rule to “eat food” means to choose minimally processed whole foods and to limit processed fare to those containing few and familiar added ingredients. Food processing has multiple risks, such as the introduction of new chemicals, the removal of fiber, and the destruction of nutrients. Regarding obesity, a problematic feature of processed food is that it tends to be loaded with the appetizing combination of sugar, salt, and fat. This hyper-palatable mix entices research animals to eat whether or not they are hungry,4 just as products containing these ingredients have done in “free range” humans. Thus, one rule regarding food choice, “eat food” (rather than processed food products) eliminates dozens of other calculations and provides a wise and actionable strategy likely to produce healthy outcomes.
Also as mentioned earlier, modern children’s attention is repeatedly drawn to strong audiovisual stimuli, such as dramatic, sexual, or violent images in games or on electronic screens. Media “hyper-reality” options have multiplied on a vast scale. Many youth are over-attached to their electronics,5 and screen time is typically sedentary, often causes sleep disruption, and displaces healthier activities. The “noise” from popular culture, gaming, and advertising crowds out important messages such as family matters and academics. Thus, more than ever, with entire industries targeting children and adolescents, caretakers face offspring demanding technologies that have the potential to harm. Parents can follow the rule to “honor silence” by enacting firm rules regarding electronics: for example, no television or video games in a child’s bedroom and/or forbidding television and video games on school nights. This will help prevent habitual use, protect sleep time, and allow the development of other interests. This tactic also decreases exposure to advertising. The cautious viewpoint is that heavy advertising is a sign of inferior merchandise and, in general, products advertised “for kids” should be avoided. Family cultures with judicious media use stand the best chance for balanced lifestyles. For families already burdened by engrained unhealthy regimens, mental health providers should be equipped to deal sensitively with the reality that when life is difficult, these small sources of pleasure and the family connections they often support are powerful reinforcers. We should strive to remain empathetic, accepting, and positive regardless of whether caregivers are interested in, or ready for, change. When faced with massive economic, social, and cultural forces driving modern lifestyles, even elegant efforts to promote change often will have humbling results. Families may need time or more information or must weather a crisis before being ready for a positive transformation. The pediatric obesity crisis arose from systemic changes in society and multiple dynamic interacting risk factors. It has been paralleled by increased mental health problems that seem interrelated. These challenges will require numerous levels of response to turn back these trends. Let us not repeat the medical community’s generally passive stance for more than 40 years while cigarette sales boomed, and the disastrous health consequences of smoking were clear. As we wait for vigorous public health efforts and more effective
JOURNAL 386
www.jaacap.org
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 4 APRIL 2014
CLINICAL PERSPECTIVES
clinical treatments, we still have ample evidence today to take a forceful stance regarding modern lifestyles’ deleterious impact on health, including obesity and mental health. Individuals and families have the capacity to build counter-regulatory mindsets that manage the challenges of modernity. Psychiatrists and their primary care colleagues should take the lead in promoting outlooks that empower families and patients to assess risks wisely, minimize exposure to hyper-stimuli, and emphasize the fundamentals of health. &
Accepted December 30, 2013. Dr. Kaliebe is with Louisiana State University Health Science Center. Disclosure: Dr. Kaliebe reports no biomedical financial interests or potential conflicts of interest. Correspondence to Kristopher Kaliebe, MD, Department of Psychiatry, Louisiana State University Health Science Center, New Orleans, LA 70112; e-mail: [email protected] 0890-8567/$36.00/ª2014 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2013.12.016
REFERENCES 1. Halfon N, Larson K, Slusser W. Associations between obesity and co-morbid mental health, developmental and physical health conditions in a nationally representative population of children age 10-17. Acad Pediatr. 2013;13:6-13. 2. Walsh R. Lifestyle and mental health. Am Psychol. 2011;66:579. 3. Tversky A, Kahneman D. Judgment under uncertainty: heuristics and biases. Science. 1974;185:1124-1131.
4. Avena N, Gold J, Kroll C, Gold M. Further developments in the neurobiology of food and addiction: update on the state of the science. Nutrition. 2012;28:341-343. 5. Rideout VJ, Foehr UG, Roberts DF. Generation M2: Media in the Lives of 8- to 18-Year-Olds. Menlo Park, CA: Henry J Kaiser Family Foundation; 2010. Available at: http://www.kff. org/entmedia/8010.cfm. Accessed December 20, 2013.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 4 APRIL 2014
www.jaacap.org
387
KALIEBE
Sugar and vegetable oils are processed, so use them sparingly! Use small plates and glasses (research shows this really matters).
SUPPLEMENT 1: THREE SIMPLE RULES: HEALTHY LIFESTYLES GUIDE FOR PARENTS This pamphlet is for parents and other caretakers. It is meant to help families focus on the most important elements of daily choices in our complex modern world. Consider these 3 “rules” of living to promote physical and mental health for children and parents, for both treatment and prevention. Human desires evolved when resources were scarce and exercise was unavoidable. In a world of plenty (comfort, food, information, and entertainment), gratifying our urges often leads to suffering. Habits have profound effects; celebrations, such as birthday parties, are less meaningful. Don’t stress over the occasional special treat, but be strict about everyday routines.
2. Get Up and Move Birds fly, fish swim, and human beings walk (or run), so get walking (or running). Make walking a daily routine and find excuses to move whenever possible. Sitting for long periods of time is harmful. Human beings, especially children, are not made to sit for extended periods. Modern lives are mostly sedentary, so leisure time should be active. Children need and naturally love active play; encourage this. Parents also need exercise (and play). They should demonstrate that exercise is important.
1. Eat Food “Eat food, not too much, mostly plants” 1 Focus primarily on this one rule in deciding what to eat: Is this real food or a processed “foodlike” factory-made product? Get as close as possible to natural, unprocessed, raw food. Eat from a garden or off a tree and you no longer need to calculate calories, carbohydrates, fat, protein, vitamins, micronutrients, etc. This math is too complex for real life, and that is part of why diets fail. The second phrases from the quote above: “not too much, mostly plants,” reflects the fact that populations who live long lives tend to consume natural, minimally processed foods, mostly plants, and only small portions or intermittent intake of animal protein (meat or dairy). Learn from diets proven to work for decades (or even centuries), rather than seeking recently invented ones. When children say they “don’t like" or “won’t eat” natural foods, assume this is an attempt to train you to provide processed junk food and that they just are not hungry enough. Use straightforward rules about when, where, and how to eat:
3. Honor Silence Avoid sensory overload! The "noise" from popular culture, gaming, and advertising crowds out important messages such as family matters and academics. Do not allow television or video games in a child’s bedroom, and forbid TV and video games on school nights. Cell phones should be off well before bedtime. Make family meals sacred and without background media clatter. Eat mindfully and at a table, not in front of the television or in a car. Sleep is crucial for health, so respect it. Don’t be hustled! The human brain is much more influenced by advertising then we consciously perceive, and children are more easily swayed. Today’s children and adolescents have whole industries selling them entertainment, electronics, and junk foods. Limiting media (especially television) also means limiting exposure to marketing. This helps children avoid the creation of unhealthy desires and allows them to accept healthy activities. Consider heavy advertising the likely sign of an inferior product.
French tradition dictates children eat only at breakfast, lunch, “goute” (afternoon snack), and dinner. No additional treats! Salad (the healthiest part) or a simple soup begins the meal. Commit to an absolute "no" (except celebrations) to problematic fare such as sodas, chips, or fast food.
Summary Learn to shun noise, electronics, processed food, sitting, and advertising. Aim to honor nature, real food, physical activity, and quiet. SUPPLEMENTAL REFERENCE 1. Pollan M. In defense of food: An eaters manifesto. New York: Penguin Press; 2008.
JOURNAL 387.e1 www.jaacap.org
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 4 APRIL 2014
Rules of Thumb: Three Simple Ideas for Overcoming the Complex Problem of Childhood Obesity Kristopher Kaliebe,
C
hildhood obesity correlates with increased internalizing disorders, externalizing disorders, attention-deficit/hyperactivity disorder, learning disorders, and academic underperformance.1 However, families rarely present to mental health practitioners to treat obesity directly, and minimal guidance exists regarding how to address this multifaceted problem during a time-limited office visit. Moreover, many behavior patterns associated with obesity, such as sedentary lifestyles, excessive media exposure, and inappropriate diets, also correlate with psychiatric diagnosis or psychological distress.2 Thus, clinicians may want to consider an approach that focuses on educating parents or other caregivers about some common factors driving these harmful modern lifestyles. The following method emphasizes to caregivers 3 simple family-oriented goals (authoritatively labeled “rules”) to assist navigating a complex, ever-evolving world that is often averse to healthy behaviors. The “rules” aim to lead caregivers toward decisions that promote physical health and mental health and are suitable as part of treatment and prevention (for a sample handout for caregivers, see Supplement 1, available online). This approach makes use of heuristics, or mental shortcuts, such as “rules of thumb.” Heuristics are a set of learned or hardwired internal cognitive biases that drive a surprisingly large amount of human choices.3 They have the advantage of being straightforward and practical, although imperfect, decision-making tools. Innate heuristics make us irrational in certain ways, including being susceptible to manipulation by
Supplemental material cited in this article is available online.
MD
marketers. However, applying judicious heuristics can effectively facilitate healthy choices, especially in challenging risk-opaque environments. Thus 3 simple “rules,” if rightly appreciated, can powerfully influence numerous prudent choices. How clinicians conceptualize problems guides their communications and treatments. The overconsumption of highly palatable caloric foods links the problem of obesity with other contemporary “overuse” challenges our children and adolescents face, such as excessive involvement with electronics. For example, “media hyper-reality” difficulties include problematic television viewing, video game play, or preoccupation with telephones or social networking. Other similar hyper-sensory modern enticements are gambling and substance abuse. All these pleasurable or engaging activities stimulate the brain’s “get more” drive. When these behavioral cycles become strengthened through habit, over time it can compromise health and functioning. This coherent story, albeit oversimplified, about how children and adolescents are at risk of these many modern temptations gives caretakers an opportunity to appreciate why several types of limit setting are critical and that these overuse problems are frequently interrelated. This wide-ranging caution can help parents better understand the world they are caught up in and allows flexibility as new challenges emerge. Regarding the framing of risks associated with sedentary modern lifestyles, a thought-provoking adage is that “birds fly, fish swim, and humans walk (or run).” Viewed in this context, it is absurd for humans, especially children, to sit for much of the day and not spend significant amounts of time moving around. The negative consequences of excessive sitting and infrequent
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 4 APRIL 2014
www.jaacap.org
385
KALIEBE
walking are profound but under-recognized. This is perhaps due to the cognitive dissonance created by the human desire for comfort and energy conservation in a world filled with couches, chairs, and mechanical transportation. This statement can help illuminate the significance of the rule “get up and move,” which speaks to avoiding excessive sitting and that frequent movement is critical for health. Furthermore, as mentioned earlier, decision making can be compromised by the enormous complexity of modern environments. Such seems the case with the dilemma of what to eat in a world replete with highly palatable food choices but often lacking in customs, standards, and traditions. Food’s ubiquitous and complex role in human health also overwhelms the common scientific approach of researching individual components, ascertaining their function, and piecing the parts together to understand the whole. There is much we do not know about modern diets, yet it is clear they lead to poor health outcomes. As a method to select what to eat, the idea of monitoring various nutrients seems attractive and is popular. However, this technique has significant limitations and, in fact, is incapable of making a simple determination of whether modern whole wheat bread (containing xanthum gum, sodium stearyl lactylate, and high fructose corn syrup) is, in fact, “healthy.” In addition, agonizing over the minutiae can lead to overvaluing certain ingredients or nutrients and disregarding the rest. This scheme also requires significant cognitive effort and is easily manipulated by marketers. Importantly, heuristics can be protective in many ways. The rule to “eat food” means to choose minimally processed whole foods and to limit processed fare to those containing few and familiar added ingredients. Food processing has multiple risks, such as the introduction of new chemicals, the removal of fiber, and the destruction of nutrients. Regarding obesity, a problematic feature of processed food is that it tends to be loaded with the appetizing combination of sugar, salt, and fat. This hyper-palatable mix entices research animals to eat whether or not they are hungry,4 just as products containing these ingredients have done in “free range” humans. Thus, one rule regarding food choice, “eat food” (rather than processed food products) eliminates dozens of other calculations and provides a wise and actionable strategy likely to produce healthy outcomes.
Also as mentioned earlier, modern children’s attention is repeatedly drawn to strong audiovisual stimuli, such as dramatic, sexual, or violent images in games or on electronic screens. Media “hyper-reality” options have multiplied on a vast scale. Many youth are over-attached to their electronics,5 and screen time is typically sedentary, often causes sleep disruption, and displaces healthier activities. The “noise” from popular culture, gaming, and advertising crowds out important messages such as family matters and academics. Thus, more than ever, with entire industries targeting children and adolescents, caretakers face offspring demanding technologies that have the potential to harm. Parents can follow the rule to “honor silence” by enacting firm rules regarding electronics: for example, no television or video games in a child’s bedroom and/or forbidding television and video games on school nights. This will help prevent habitual use, protect sleep time, and allow the development of other interests. This tactic also decreases exposure to advertising. The cautious viewpoint is that heavy advertising is a sign of inferior merchandise and, in general, products advertised “for kids” should be avoided. Family cultures with judicious media use stand the best chance for balanced lifestyles. For families already burdened by engrained unhealthy regimens, mental health providers should be equipped to deal sensitively with the reality that when life is difficult, these small sources of pleasure and the family connections they often support are powerful reinforcers. We should strive to remain empathetic, accepting, and positive regardless of whether caregivers are interested in, or ready for, change. When faced with massive economic, social, and cultural forces driving modern lifestyles, even elegant efforts to promote change often will have humbling results. Families may need time or more information or must weather a crisis before being ready for a positive transformation. The pediatric obesity crisis arose from systemic changes in society and multiple dynamic interacting risk factors. It has been paralleled by increased mental health problems that seem interrelated. These challenges will require numerous levels of response to turn back these trends. Let us not repeat the medical community’s generally passive stance for more than 40 years while cigarette sales boomed, and the disastrous health consequences of smoking were clear. As we wait for vigorous public health efforts and more effective
JOURNAL 386
www.jaacap.org
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 4 APRIL 2014
CLINICAL PERSPECTIVES
clinical treatments, we still have ample evidence today to take a forceful stance regarding modern lifestyles’ deleterious impact on health, including obesity and mental health. Individuals and families have the capacity to build counter-regulatory mindsets that manage the challenges of modernity. Psychiatrists and their primary care colleagues should take the lead in promoting outlooks that empower families and patients to assess risks wisely, minimize exposure to hyper-stimuli, and emphasize the fundamentals of health. &
Accepted December 30, 2013. Dr. Kaliebe is with Louisiana State University Health Science Center. Disclosure: Dr. Kaliebe reports no biomedical financial interests or potential conflicts of interest. Correspondence to Kristopher Kaliebe, MD, Department of Psychiatry, Louisiana State University Health Science Center, New Orleans, LA 70112; e-mail: [email protected] 0890-8567/$36.00/ª2014 American Academy of Child and Adolescent Psychiatry http://dx.doi.org/10.1016/j.jaac.2013.12.016
REFERENCES 1. Halfon N, Larson K, Slusser W. Associations between obesity and co-morbid mental health, developmental and physical health conditions in a nationally representative population of children age 10-17. Acad Pediatr. 2013;13:6-13. 2. Walsh R. Lifestyle and mental health. Am Psychol. 2011;66:579. 3. Tversky A, Kahneman D. Judgment under uncertainty: heuristics and biases. Science. 1974;185:1124-1131.
4. Avena N, Gold J, Kroll C, Gold M. Further developments in the neurobiology of food and addiction: update on the state of the science. Nutrition. 2012;28:341-343. 5. Rideout VJ, Foehr UG, Roberts DF. Generation M2: Media in the Lives of 8- to 18-Year-Olds. Menlo Park, CA: Henry J Kaiser Family Foundation; 2010. Available at: http://www.kff. org/entmedia/8010.cfm. Accessed December 20, 2013.
JOURNAL OF THE AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 4 APRIL 2014
www.jaacap.org
387
KALIEBE
Sugar and vegetable oils are processed, so use them sparingly! Use small plates and glasses (research shows this really matters).
SUPPLEMENT 1: THREE SIMPLE RULES: HEALTHY LIFESTYLES GUIDE FOR PARENTS This pamphlet is for parents and other caretakers. It is meant to help families focus on the most important elements of daily choices in our complex modern world. Consider these 3 “rules” of living to promote physical and mental health for children and parents, for both treatment and prevention. Human desires evolved when resources were scarce and exercise was unavoidable. In a world of plenty (comfort, food, information, and entertainment), gratifying our urges often leads to suffering. Habits have profound effects; celebrations, such as birthday parties, are less meaningful. Don’t stress over the occasional special treat, but be strict about everyday routines.
2. Get Up and Move Birds fly, fish swim, and human beings walk (or run), so get walking (or running). Make walking a daily routine and find excuses to move whenever possible. Sitting for long periods of time is harmful. Human beings, especially children, are not made to sit for extended periods. Modern lives are mostly sedentary, so leisure time should be active. Children need and naturally love active play; encourage this. Parents also need exercise (and play). They should demonstrate that exercise is important.
1. Eat Food “Eat food, not too much, mostly plants” 1 Focus primarily on this one rule in deciding what to eat: Is this real food or a processed “foodlike” factory-made product? Get as close as possible to natural, unprocessed, raw food. Eat from a garden or off a tree and you no longer need to calculate calories, carbohydrates, fat, protein, vitamins, micronutrients, etc. This math is too complex for real life, and that is part of why diets fail. The second phrases from the quote above: “not too much, mostly plants,” reflects the fact that populations who live long lives tend to consume natural, minimally processed foods, mostly plants, and only small portions or intermittent intake of animal protein (meat or dairy). Learn from diets proven to work for decades (or even centuries), rather than seeking recently invented ones. When children say they “don’t like" or “won’t eat” natural foods, assume this is an attempt to train you to provide processed junk food and that they just are not hungry enough. Use straightforward rules about when, where, and how to eat:
3. Honor Silence Avoid sensory overload! The "noise" from popular culture, gaming, and advertising crowds out important messages such as family matters and academics. Do not allow television or video games in a child’s bedroom, and forbid TV and video games on school nights. Cell phones should be off well before bedtime. Make family meals sacred and without background media clatter. Eat mindfully and at a table, not in front of the television or in a car. Sleep is crucial for health, so respect it. Don’t be hustled! The human brain is much more influenced by advertising then we consciously perceive, and children are more easily swayed. Today’s children and adolescents have whole industries selling them entertainment, electronics, and junk foods. Limiting media (especially television) also means limiting exposure to marketing. This helps children avoid the creation of unhealthy desires and allows them to accept healthy activities. Consider heavy advertising the likely sign of an inferior product.
French tradition dictates children eat only at breakfast, lunch, “goute” (afternoon snack), and dinner. No additional treats! Salad (the healthiest part) or a simple soup begins the meal. Commit to an absolute "no" (except celebrations) to problematic fare such as sodas, chips, or fast food.
Summary Learn to shun noise, electronics, processed food, sitting, and advertising. Aim to honor nature, real food, physical activity, and quiet. SUPPLEMENTAL REFERENCE 1. Pollan M. In defense of food: An eaters manifesto. New York: Penguin Press; 2008.
JOURNAL 387.e1 www.jaacap.org
OF THE
AMERICAN ACADEMY OF C HILD & ADOLESCENT PSYCHIATRY VOLUME 53 NUMBER 4 APRIL 2014
