Indiana University Research & Creative Activity


Volume 30 Number 1
Fall 2007

<< Table of Contents

Gilbert Liu
Gilbert Liu
Photo by Rocky Rothrock, Visual Media, IUPUI

A Leaner, Greener Childhood

by Karen Garinger

Here's a typical day for 9-year-old Rocío, who lives in a large Midwestern city: She and her brothers and sisters awake at 8 a.m. Their mother, a night-shift cashier at a convenience store, is asleep when the clean-faced, neatly dressed, and hungry children leave their apartment. They stand on the curb, just steps from their home, under strict orders not to wander, not even to play on the basketball court across the street. Their mother considers the neighborhood dangerous, and she's right.

A school bus pulls up and takes the kids five blocks to their school, where they file into the cafeteria for the free breakfast program. Rocío chooses a ham, cheese, and egg burrito; hot chocolate; and cotton-candy-flavored yogurt. There's no time afterward to play outside, so Rocío goes straight to class and settles in for the morning. Soon it's time for lunch (fish sticks, applesauce, grape juice, and peanut-butter cookies), followed by a 10-minute recess spent trading colorful stickers with her friends. Then Rocío passes much of the afternoon in the computer lab. She goes to a brief gym class at the end of the school day, where the activity is volleyball. All of the kids are in their street clothes; some wear sneakers, but others wear shoes not suitable for running and jumping.

Next, Rocío goes to the after-school program in the library. After doing their homework, children can work on a craft or watch a movie. Rocío sits on the floor in front of the DVD player and eats the supplied snacks--chocolate-chip granola bars, cheese crackers--and drinks lemonade. The kids are tired and cranky, and the staff gives them second helpings to see them through to pickup time.

Dropped off at home by the school bus, Rocío does household chores in the small apartment, eats dinner (pepperoni pizza, breadsticks with cheese dip, chicken wings, and a large soda), plays video games with her brother, and then goes to bed. Today, like most days, she has taken in many more calories than she has expended, which is why this bright, cheerful, outgoing child has a disturbing health problem: she's seriously overweight and becoming more so.

Rocío is a fictionalization, but the circumstances of her life are all too real. Nearly every day, Dr. Gilbert Liu observes kids and their families, particularly low-income families, confronting the complex problems of childhood obesity. An assistant professor of pediatrics at the IU School of Medicine in Indianapolis and a general pediatrician at the children's clinics in Riley and Wishard hospitals, Liu treats patients who conform to the trend seen nationwide: a tripling of the percentage of overweight youngsters since the 1980s. His research into this situation has been innovative and interdisciplinary, and, though his methods may be technical, Liu's findings are easy to understand: Kids who live in greener spaces are less likely to be overweight.

If You Build It . . .

"A neighborhood approach to identifying the risk factors of obesity and to helping with prevention makes a lot of sense," says Liu. "The rapid increase in the rate of childhood obesity points clearly to environmental factors. In our modern American lifestyle, it's so easy to overeat; there are so many tasty, inexpensive foods out there, and it's also really easy to be completely sedentary."

Expanding on studies that have shown that the "built environment" affects adults' likelihood to be obese, Liu and his co-researchers investigated the impact of children's daily surroundings on their weight. "We started to analyze neighborhoods, particularly those where our patients live, to come up with more evidence about whether particular factors in the environment are risk factors or protective factors for weight status," he says.

Liu's research partners were IUPUI faculty members Jeffrey Wilson of the Department of Geography and Rong Qi of the Department of Medicine, as well as Jun Ying from the University of Cincinnati. Information about the residences of overweight pediatric patients came from the Regenstrief Medical Record System (RMRS). The RMRS, a huge, comprehensive medical records database housed at the Regenstrief Institute at IU's School of Medicine, made it possible to identify health data on more than 7,000 overweight children between the ages of 3 and 18 who had made well-child visits to IU Medical Group clinics in Indianapolis in 2000.

This information was overlaid with satellite-generated images indicating the prevalence of vegetation around the children's residences and was also compared with information on neighborhoods from the Indianapolis city government, the U.S. Census Bureau, and the work of other researchers.

"The premise of the research is that exposure to green landscapes plays a role in promoting psychological and physiological well-being that can explain, at least in part, spatial patterns of overweight and obesity in children," write Liu and his colleagues in the May 2007 issue of The American Journal of Health Promotion. "Time spent outdoors is a clearly established correlate of physical activity in children; access to parks or other outdoor play spaces has also been associated with increased physical activity in youth."

Besides determining how green the patients' neighborhoods are, the researchers considered proximity to various food sources, such as fast-food restaurants and supermarkets, to test the theory that those children with the greatest access to the lower-calorie and fresh food choices available at supermarkets would have a lower prevalence of obesity.

They found that in urban neighborhoods (those with the highest population density), "the greener the neighborhood was, the less likely it was for the kids to be obese," Liu says. Among the children with suburban addresses, green surroundings did not appear to have a protective effect against obesity, but closeness to a large supermarket did.

An Ounce of Prevention

Establishing the link between a greener environment and leaner kids is only a preliminary step in Liu's efforts to address weight problems in children. "We'd like to look at physical activity and dietary behavior in light of this information," he says. "It would be great if we could connect environment to behavior and behavior to outcomes. There seems to be a lot of evidence that the way we design our neighborhoods determines how active we are and what we eat. Findings like this suggest that we need to think about ways to promote physical activity through making neighborhoods more amenable to walking and biking and playing outdoors."

And given that those children who are most at risk for obesity are the same children who are most at risk in general--children from low-income families, from minority groups, from urban neighborhoods facing a multitude of challenges--"we need to make it easier for them to get access to fresh foods, a more nutritious diet, and give them more of a green infrastructure, such as parks, for getting enough exercise," Liu says.

Liu recommends a multifaceted movement against childhood obesity that's as commanding and widespread as the anti-tobacco campaigns of the last few decades. "We need to hit it at the individual, family, community, and policy levels," he says. Though the anti-smoking model has had its successes, anti-obesity efforts must concentrate much more heavily on prevention.

"If you follow weight-loss programs over the years, there's an 80 to 90 percent failure rate," he says. "We might be able to get people to lose weight in the short term, but we're abysmal at getting people to maintain weight loss. Once you get into obesity treatment, the odds are against succeeding. So preventing obesity is our hope."

And the earlier the prevention starts, the better. "Definitely by the time kids are in grade school, maybe even when they're toddlers, we need to be reaching them," Liu says. He predicts that the methods for reaching them successfully will probably differ from those that are persuasive for adults.

"The main reason we want to fight obesity is to prevent cardiovascular disease, heart disease, diabetes, and all the terrible outcomes that being overweight makes you much more likely to suffer," he says. "But it doesn't really motivate most kids when you say, ‘You need to be at a healthy weight because it'll protect you from having a heart attack 40 years down the road.' In the near term, we know that for kids, things like body image and teasing and the social aspects are what they care about more."

Liu worries about his overweight patients in both the long and short term. He sees that they often lack self-esteem, show signs of depression, and appear to have low social support.

He counsels these patients and their families to work together to develop a consciousness of how changing behavior can result in a healthier, happier life.

"I question overweight kids about what kinds of foods they like, what portion sizes they take, whether they go back for seconds, what physical activities they like, and from there we can identify some things to work on," he says. "I ask questions such as ‘Do you feel safe walking in your neighborhood?' and ‘Do you think you could do some outdoor activities with your friends or with your family?' Then we set up a plan and have follow-up visits to track their progress. We also identify partners such as dieticians, coaches, role models, anyone who can help them in this effort." Liu would like to see schools get more involved in fighting obesity by offering children more healthful meals and more opportunities for physical activity.

But no matter how motivated overweight children are to change their lifestyle, no matter how much support they receive from their families, health-care providers, and schools, a fitness-unfriendly environment still represents a substantial barrier to a healthy weight. In a recent interview in the "Ask the Doctor" column on the Indianapolis Star newspaper Web site, Liu said, "The more grass that's underfoot, the more likely kids are to be active." That's why he advocates strongly for a public investment in making our nation's neighborhoods greener.

Karen Garinger is the senior editor in the Indiana University Office of Creative Services in Bloomington.

Related Articles:

Behaving Healthy

Pulling Our Weight

Forced Feeding