Interaction

Spring 2008

Child obesity and the need for social movement

The Stanford Prevention Research Center has organized a Latina girls dance troupe called ECHALE, which performed recently at Clark Center after an Entrepreneurship Week session devoted to battling child obesity. In the two-year randomized controlled trial in Redwood City schools, researchers are studying the efficacy of the dance program and reduced television-viewing in diminishing weight gain among the girls.
Photo: Gennady Chuyeshov

"Epidemics cannot be controlled at the level of the individual," said Lisa Chamberlain, an assistant professor of pediatrics."That's true for cholera, and it's true for obesity."

What's needed, she said at a recent talk at the Center for Healthy Weight (CHW), is better policy and an awareness of the disparate linkages that have led us to a situation in which one-third of all children born in this decade will develop type-2 diabetes because they are overweight. Half of all Mexican American boys and half of all African American girls are on track to develop the disease.

Fiscal policy, food prices, advertising, city planning, family life, international trade, the public school system and television are all part of the story. It's an expensive and dangerous story whose solution requires a vast array of expertise and imagination.

The director of CHW is Thomas Robinson, professor of pediatrics.

Thomas Robinson

"From very early on in my career, I was exposed to the fact that factors in determining health lay outside the medical care system," he said. He first realized this as a Stanford biology major, when he started wondering why healthcare spending wasn't going to prevention. Later on, in medical school, he worked with John Farquhar, founder of the pioneering Stanford Heart Disease Prevention Program, today called the Stanford Prevention Research Center, which spans several departments.

"As a researcher, to make the greatest impact, I had to look across the disciplines. I had a different perspective, a [World Health Organization] approach to health that was very broad and emphasized health and wellbeing," he said.

Other centers, he said, focus on just research, or just advocacy or just medical care."But we wanted to do it all, building on our strengths, from basic research to policy, linking physicians with public schools, community advocates, education experts, working together through initiatives such as soccer and dance programs.

"What's unique about us is that we put an advocate, a lab researcher, a clinician and a community program together. Stanford School of Medicine stresses translational medicine, from benchside to bedside, but if you really want to disrupt business as usual, put a community advocate in the mix as well."

Entrepreneurship Week

You might also think about putting a venture capitalist, a mechanical engineer, a surgeon and an entrepreneur there. One of the events at Stanford's Entrepreneurship Week in winter quarter did just that. Sandra Miller, managing director of the Biodesign Program, was referred by someone at the Graduate School of Business to Karen Kemby, director of business development at Lucile Packard Children's Hospital, who works with Robinson at CHW. They all put their heads together and came up with an event that would combine entrepreneurship and human health.

At a packed gathering in Clark Auditorium, Robinson launched a challenge: Let's reduce pediatric obesity. A panel of experts then responded, offering the particular challenges in their field: developing surgical methods and devices that work for kids; raising money for research; feeding healthy meals to schoolchildren.

After that, representatives of the medical school's Biodesign Program called on audience members—students, engineers, parents, members of the community—to huddle in small groups to brainstorm with strangers. The resulting ideas were announced at the end of Entrepreneurship Week. There were nine submissions, and awards were made in three categories: policy, video games and medical devices. Winners will get to meet with the panel member who can most help them; the medical device inventor, for example, will sit down with venture capitalist Dana Mead, a partner at Kleiner Perkins Caufield & Byers and a board member of the Packard hospital.

Another of the Entrepreneur Week speakers was alumna Pat Christen (AB '82, Values, Technology and Society), president and chief executive officer of HopeLab, a nonprofit research and innovation organization that helps children with chronic illness. The organization's current initiative is called Ruckus Nation, which recently sponsored a worldwide competition for ideas to get kids moving. More than 400 teams from 37 countries and 41 states entered ideas.

The 10 category finalists (middle school, high school, college and other) each received $25,000; among them was David Ngo, a 27-year-old Stanford graduate student in product design who created a game called Scoot, whose display poster read,"Imagine if you mashed up musical chairs and a disco ball."

Many of the finalists drew their inspiration from the arcade and video game Dance Dance Revolution (DDR), in which youngsters gain points for speed and accuracy by moving their feet on a special mat to corresponding dance steps displayed on the screen. But most went one step further, making their devices and games more interactive than DDR.

Yet another idea competition around the problem of child obesity was undertaken by the members of a mechanical engineering class, Transformative Design, taught in winter by a team of professors led by Bernard Roth and also including anthropologist Sarah Jain. Class members divided up into teams according to interest and then used interactive technology to develop products that encourage behavioral transformation.

One of the teams decided to tackle child obesity. The four graduate students, one each from Mechanical Engineering, the Graduate School of Business, Environmental Engineering and Computer Science, came up with two ideas. The first one drew from Dance Dance Revolution, like so many of the Ruckus Nation projects. It was scrapped, among other reasons, because the team did not want a game that might be prohibitively expensive. The second, which they call"Fit Full Fun," was given a test run at the fourth birthday party of the nephew of team member Sun K. Kim. It entails standing before a screen and jumping back and forth and side to side to catch healthy food items as they descend, and then putting them into a basket.

‘Stealth interventions'

Robinson, the Irving Schulman, M.D., Endowed Professor in Child Health, is interested in social movement theory, both the theoretical kind and the more obvious kind. Like soccer. Like DDR. Like folk-dancing. Anything to get kids moving. Christen's guiding slogan,"Lead with fun and health will follow" is similar. Don't call it exercise, she said, call it fun.

As a result, Robinson and his medical colleagues have obtained federal funding to work with a sports league in East Palo Alto aimed exclusively at overweight children. Asked if there might not be a stigma to playing on the fat kids' team, he replied that if half the kids are overweight, it's no stigma. For the first time in their lives, he said, the children enjoyed sports. Parents don't have to take their children to weight clinics or other special appointments, and the kids aren't home eating junk. It's cheap, it's easy and it works.

Robinson calls such approaches"stealth interventions," another way of saying that the kids are having too much fun to notice they're exercising.

How did it get to the point that children don't know how to play? How did we come to think that"kids' food" is different from regular food? Children have become expert consumers; Robinson published a study last year revealing that even 3-to-5-year-olds chose what they thought were McNuggets over identical processed chicken in different packaging. If aiming cigarette advertising explicitly at young people gets the anti-tobacco forces particularly riled, what about the advertising of certain fast-food giants who tuck in stuffed animals and colorful plastic drinkware along with the nutrient-bereft nuggets? What about the fact that those plastic cups, generally filled to the brim with corn syrup, are enormous?

Psychologist Sam McClure works on an area called intertemporal choice or temporal discounting—our ability to make decisions whose benefits are distributed in the future. For example, saving now to spend later, or eating food to satisfy an urge now versus eating something else to ensure good health in the future. He and Robinson are in conversations about linking their research.

"One question may be how different policies influence the way we think about health-related choices and what the consequences of this are on behavior," McClure said. He has used imaging techniques to study how the brain processes delayed and immediate rewards, and he is helping organize a conference this fall at the National Institutes of Health called"Neuroimaging in Obesity Research."

Public policy

Advertising restrictions, snack taxes, school lunches, physical education classes and commodity price supports all affect whether children end up in the overweight soccer league, which brings us back to Chamberlain's observation: We need policy. Robinson and others believe that change must originate with children themselves and that some inner transformation must take place; but it is also true that punitive or redirecting policies can be part of the story.

The negative publicity surrounding the documentary Super Size Me, for example, led McDonald's to cut back on serving sizes. (Executives said the decision had nothing to do with the film. The enormous containers originated with the observation in the 1970s that people would be embarrassed to order seconds but not to order a huge first.) During its last session, Congress considered an amendment sponsored by Tom Harkin, D-Iowa, to the Farm Bill that would ban the sale of junk food in schools. There are a host of similar state and local measures wending their way through committees, and CHW staff is watching every move they make. (California had a junk food tax until 1992, when the California Grocers Association, using the effective slogan"Don't Tax Food," managed to persuade 60 percent of state voters to repeal it.)

There are moral, economic and social arguments in favor of public policy aimed at obesity, says Michelle Mello, a graduate of Stanford's Program in Ethics in Society and today a professor of health policy and law at Harvard's School of Public Health. She has written on obesity as a potential new frontier of public health law and has examined fast-food litigation, in which plaintiffs have sought damages for their health problems. Personal choices, she says, are reaping public ills.

"I did the Ethics in Society Honors Program as a means of learning how to think systematically about the ethical dimensions of problems of major public health significance," she said."At the time, I did not know what it meant to analyze problems from an interdisciplinary perspective. But today I know that solutions to the obesity problem are likely to require interdisciplinary research and policy-development efforts. The more we learn about obesity, the more we understand that it has multiple, interacting causes, ranging from the level of the gene to the level of the social structure."

So it is complex, as complex as the 39 ingredients in a Hostess Twinkie, which, despite all the packaging and processing, is still cheaper than an apple. It sounds like something an economist, a psychologist, a nutritionist—and a soccer coach—could fix.