Julie Kugel, OTR/L, OTD, was working on her doctorate online through Loma Linda (Calif.) University when she began grappling with the disturbing fact that the obesity epidemic in the U.S. starts at a very young age. To learn more about the causes and possible solutions, Kugel launched a healthy occupation program for middle school girls at a Boys & Girls Club in Rochester, Wash.
During initial interviews with participants, the girls talked with Kugel about their daily routines — reports that were troubling and at times upsetting.
One girl said she played online games for 20 to 30 hours per week. Another, who admitted she regularly was teased and bullied at school for being overweight, drank four cans of Amp Energy drink every day to help her get through school. Her parents often went through a fast food drive-thru for dinner, and during physical education class she struggled with having less stamina than her peers.
Before launching her project, Kugel conducted an extensive literature review on the topic of childhood obesity, and she discovered that programs focused on reducing a child's weight or body mass index were not only unsuccessful, but also lowered the child's self-esteem.
"I found that there was not a lot in the literature about how to look at the child as a whole," said Kugel, who now is an occupational therapist for the Centralia and Chehalis school districts in Washington. "I wanted to try teaching them about wellness and balance, and how our daily occupations can impact our health."
Kugel is not alone. There is growing momentum in the occupational therapy field to explore how OTs can play a greater role in combating the childhood obesity problem. In the summer, the American Occupational Therapy Association formed a childhood obesity work group tasked with understanding the problem from multiple perspectives and exploring the role that OTs can have in prevention and intervention.
"I'm passionate about this issue because it is an epidemic, and we aren't paying much attention to it," said Michael Pizzi, OTR/L, PhD, FAOTA, a member of the work group and an assistant professor at Shenandoah University in Virginia. "We learn our choices, habits and routines at an early age, and I believe OTs have the skills to help children and families really look at how they can start making healthy food and lifestyle choices within the constraints of their environment."
Discovering new routines
According to the Centers for Disease Control and Prevention, about 17% of children and adolescents ages 2 to 19 are obese, and the prevalence of obesity in that age group has tripled since 1980.
Alarming statistics like these motivated Kugel to create a seven-week program. She started by asking the girls to name their occupations throughout a typical day, then they discussed the differences between healthy and unhealthy occupations, and how these choices can affect their bodies. The next week, they learned about nutrition, such as how to read a food label, real food versus fake food and the food pyramid. In the following weeks, the group discussed beauty — and how our perceptions are altered by the media — and stress management.
Although Kugel did not have quantitative results, the feedback from the girls throughout the program was promising. The girl who had been teased about her weight had cut down to just one energy drink per day. She had started taking a walk every evening with one of her relatives and had noticed she felt less out of breath during physical education class. When taken to a fast food restaurant for meals, she would choose a healthy salad.
"It can be intimidating to move past some of our typical practices, but it is really rewarding to see kids changing," Kugel said. "There is such a great need for more education about healthy occupations, and we are missing out if we ignore what is going on in our community."
Like Kugel, Cynthia Lau, OTR/L, PhD, BCP, an assistant professor at Touro University Nevada, said she believes OTs could make a significant dent in the childhood obesity problem. Lau's department partnered with the City of Henderson (Nev.) Recreation Department to launch the "Healthy Choices for Me" program at two low-income elementary schools. For 90 minutes, three times a week during the after-school program, graduate students from the university taught children about nutrition, physical activity and goal setting.
The program leaders replaced the traditional high-carbohydrate snacks at the schools with healthy snacks such as salads or smoothies. The children helped prepare the snacks and learned about the vitamins and fiber in these foods — and how they will give them energy to play and learn.
They also discussed the importance of physical activity. The students learned how hula-hooping and jumping rope are easy ways to get exercise at home instead of watching TV or playing computer games. The graduate students also taught the children active games, such as Capture the Flag, Simon Says and Freeze Tag.
The graduate students helped the children create personal goals for exercising and eating. "It was important for the children to come up with their own goals so they could pick something meaningful to them and have ownership," Lau said. "It could be something like trying one new vegetable per week, or doing 20 push-ups per day. To be client-centered, the goals have to be derived from the client, and this is one of the ways OT is unique."
The children were given a choice of carrots or cookies on the first day of the program, and the majority chose cookies. When given the same choice 10 weeks later, more of the students chose carrots.
Power of prevention
For Lau, it was important to include all of the children in the program, rather than focusing only on obese children. One of the reasons is she believes obesity prevention is a critical tactic for combating the problem in this country.
Prevention also is one of the goals of the AOTA childhood obesity work group, which soon will release an information sheet on obesity for practitioners that provides an overview of the obesity problem and references and links for those who want to incorporate obesity prevention and intervention into their practices. AOTA also has published a tips sheet available to the public that focuses on why play is important, and the different ways families can promote play in early childhood and elementary, middle and high school, which is available at aota.org under Pediatrics.
Lau's hope for the future is that the field of occupational therapy will evolve to include healthy lifestyle education as part of the treatment protocol for patients and the community at large. "Right now, we treat the disability, but we are not preventing further disability by coaching children to make healthy choices in their environment," Lau said. "The more OTs who address this issue, the better off we will be. If we do not deal with it now, what will be the impact on the health of the nation and the healthcare system?"