Steadygrow is a unique, private and positive online resource to help parents understand, monitor and gain feedback about their children’s weight over the long term.  In various forms it has applications for most children.

Whilst steadygrow is useful to help educate all parents on their children’s weight status, it has been designed specifically to monitor the vast majority of children who are considered to be healthy and whose parents currently have no issues about and/or seek no input with regard to their children’s weight.  This is a crucial group to monitor because it is from the ranks of the upper percentiles of this main group that we are most likely to see future cases of obesity emerge.¹  It has been recognized that children whose weight is in the upper percentiles (above the 50th percentile) are more likely to gain excess weight in future than those in the lower percentiles.  Therefore, even if they are healthy, these children need to be monitored and their parents given feedback so that unhealthy gains in weight can be detected early and acted on.  As is stated in the opening pages of the 2003 NHMRC Clinical Practice Guidelines for the Management of Overweight and Obesity in Children and Adolescents: “Once a child or adolescent is on an overweight or obese percentile, it is unlikely that they will revert spontaneously to a lower weight percentile.”² (my italics)  These are the children for whom prevention and early intervention has the highest chance of success, if only they can be recognized now, which is what steadygrow offers.

Parents often reassure themselves that their child will grow out of any excess body fat they carry as they grow up.  Unfortunately this is only the case for about 30 to 50% of children.  This means that one in two children will remain obese or overweight into adulthood and the closer they are to these levels in late childhood the more likely this is to happen.  Children who are carrying higher than necessary levels of fat may slim out as they go through their adolescent growth spurt, but if they have not ingrained good habits of eating and activity, the situation will likely recur when upward growth ceases. As importantly, obesity in childhood is associated with increased adult cardiovascular morbidity and mortality, regardless of adult weight.³

My experience as a pediatrician is that parents value feedback about their children’s weight.  Currently the only way they can get this is by visiting their family doctor, being weighed and measured, and having those measurements entered onto a body mass index (BMI) chart which the doctor then interprets for them.  The body mass index percentile charts for boys and girls are inherently difficult to understand.

A number of factors prompted me to develop the steadygrow program:

• Childhood obesity is becoming recognized as a major health issue.
• There are calls to develop new and innovative programs.
  
• Most people do not understand the medical model for recognizing childhood obesity.
• Most parents are trying to prioritize their lives in order to do the best for their children.  They can best do this with quality information that is tailored to their specific children.
• There is a simple way to make the BMI charts understandable for individuals via the Internet.
•  Weight monitoring is a life long issue and the sooner it begins the more valuable the information becomes to the individual over time.
• From a practical perspective, small inaccuracies in measurement do not matter because the general approach for the majority of children on any one occasion is broadly similar.  This means that well instructed parents should be able to weigh and measure most children themselves so long as they have adequate equipment.
• Keeping all information under the control of the parents, and, later, the child themselves supports the concept of individuals taking responsibility for themselves and their families.
• I like the idea of being able to provide an information service to all parents, not just those who could consult with me, personally, as a paediatrician.
• Most countries have an increasing rate of Internet usage
• Broadband access to the Net is increasing.
• Obesity is a very sensitive subject, with bias and discrimination existing even within the health system.  The privacy of online education is an obvious way to help deal with people’s fears about this.
• There are major issues about a declining family doctor workforce.
• Parents need appropriate encouragement about when to see their family doctor about childhood weight issues and this can be easily encouraged online.

Most programs to encourage good health in children currently focus on healthy eating, and adequate physical activity.  Parents are encouraged to treat all children the same, and by generally improving family eating and activity pattern, to improve the health of all family members.  This message is now being used to encourage parents to prevent or minimize obesity in their children.

 There is a fear that bringing any attention to an individual child’s weight will irreversibly damage that child’s self-esteem.  There is also a fear that any focus on weight will damage body image and increase the risk of the development of eating disorders.  There is a pervasive sense that to weigh a child is somehow bad and that if one advocates weighing then, almost by definition, one is over-focused on weight.  There are also many people who do not even realize that there is an internationally accepted guide for recognising the probability of overweight and obesity in children (The BMI for age and gender percentile charts).

We are not a perfect society.  We cannot put in place perfect eating and exercise programs for all our children all the time. Busy parents constantly prioritize their time and where they focus their energies in their children’s upbringing.  If parents do not realize that their child is overweight or obese then they are unlikely to alter what they are doing to change the status quo, if they already perceive that their children are getting enough exercise and eating OK.

It is my belief that if parents can receive private, easily accessible, non-judgemental feedback about their child’s weight status they will find this information valuable.  It will enable them to hone the eating and activity levels for their individual children.  And there comes a point when such strategies must be individualized.  I give the example of a parent with 3 children, all of whom have been taught to clean their teeth, and all of whom have been supervised over time to ensure they know what to do.  Consider that one night, all 3 children return from teeth cleaning and that their teeth are checked by their parent.  One child has remnants of food still lodged deep in the molar fissures.  How many children does that parent send back to re-clean their teeth?

The answer of course, is one; the child who, despite all the good work invested thus far, has not managed to clean their teeth adequately for good health.  Any parent who sent back all 3 children for another go would be roundly bucketed by any right thinking clean-toothed child…  And yet this is exactly what we are recommending families do in managing their children to minimize obesity.  Treat everyone the same no matter what.  Family based approaches can go only so far, and one risks alienating the goodwill of the many if one insists on treating everyone the same.  All children are not the same, and, even within one family, there can be children whose innate approach to eating and exercise differ markedly.  I believe that it is empowering to parents to be able to have feedback on the BMI of each of their children.  It will help them decide which of  their children need further help and encouragement with their healthy eating and healthy exercise.  And the beauty of it is that the child need not even know what is occurring.  All they might notice is that suddenly Dad is a bit stricter about that second helping, or Mum seems to be more interested in that afternoon walk with them.  All the child needs to be told is that being weighed and measured is a part of Mum and Dad’s job to help keep them healthy.  As children grow and ask more questions answers can be framed in a positive light that is not detrimental to self esteem.  Using weight feedback to punish or humiliate a child reflects a characteristic within that parent, not within the system of feedback.  The feedback is neutral.  It is the value that parents choose to place on it that imbues that feedback with its significance.

There is currently very little feedback given to parents about their child’s weight status and yet we have a society of children and adults terrified of being too fat.  I believe that part of the solution here is to help people to understand that their weightzone does not define who they are; to help people understand that to know their weightzone is helpful, not hurtful, because it just is.  In fact, I believe this information, if given without drama, and with an underlying acceptance of the child will help that child, particularly as they enter adolescence, to understand what weight is appropriate for them, rather than giving them no baseline with which to understand themselves, and leaving them to aspire to unrealistic and unhealthy weights that they read about in their idols.  By encouraging a healthy weight, girls may be less likely to diet and thus less likely to enter the endless roundabout of losing and gaining weight, a cycle which is thought to increase weight difficulties in the long run.

Regarding the possibility of encouraging eating disorders, I would like to quote a paragraph from The Cochrane Review entitled “Interventions for treating obesity in children”:⁴  “The proposed relationship between treating obesity and eating disorders, particularly in young populations, may further limit research in this area. However, while eating disorders are clearly important public health issues and while dieting may be a risk factor for eating disorders in some people, the literature about this relationship remains equivocal, with some studies finding no association⁵ and others suggesting that an association does exist in some women.^6,7  It is important to acknowledge that the proportion of the population who are obese far exceeds the proportion of the population who have eating disorders. Furthermore, we need to reiterate that many obesity treatments are not, by default, about "dieting". However, it is important that obesity treatments make assessments of potential unintended effects since there is a lack of data on this aspect of treating obesity in children.

The steadygrow program has a number of features to support parents in a positive approach to weighing and managing weight for health.  It gives specific “safety guidelines” about how to approach weighing so as not to make it a negative or overly imbued situation.  It does not encourage dieting, but rather a hold-weight-steady approach to enable children to “grow into” their weight.  It updates feedback on how many months needed to “hold-weight-steady” at each weight entry point.  This means the parents always have a goal for the future, rather than looking back to see if they have “passed or failed” on the previous goal.  The program has a unique feature which allows the child’s doctor to nominate a “preferred weight” which can be noted in the program very simply by the parent, in cases where a child’s build is felt to require a different approach than that available purely with reference to BMI charts.  This preferred weight is then projected into the future to give parents specific guidance for that child.  The  steadygrow program encourages parents to make use of the extensive information about “Healthy Eating – Healthy Action” available on the Ministry of Health website in New Zealand.

The steadygrow program is not intended to replace the input of family doctors.  Recent research in Australia has however revealed big issues in the approach to monitoring for childhood obesity by family doctors in that country.⁸  There may be similar issues in New Zealand.  This study identified that family doctors often did not weigh and measure children when they had appropriate opportunity to do so.  It also found that one of the things that did prompt them to weigh and measure was a request from the family.  I believe that by educating and interesting parents, through steadygrow, they will be more likely to request weighing and measuring from their family doctor and thus support these doctors in this aspect of their care.  The steadygrow program has a built-in ability for parents to record what set of scales was used to take their child’s weight, so that family doctor weights can be specifically identified to help pick up discrepancies with parents’ own scales if they are also being used.  One final note about this study of family doctors was that it identified big issues with regard to the accuracy and maintenance of their weighing and measuring apparatus.

The steadygrow program recommends that all parents who are concerned that their child may be overweight, and all parents whose child falls in the “obese” category on BMI see their family doctor for review.  It also recommends all children have their height formally measured (eg by their family doctor) at least once a year, and that all children under 4 years of age have their height and weight measured by their family doctor because at these young ages, inaccuracies in weighing and measuring are more likely to be significant.

The steadygrow program also educates parents about the value of the waist circumference measurement⁹ and allows them to track their child’s waist circumference over time.  This aspect of tracking waist circumference over time may be particularly important in terms of monitoring levels of fat.¹⁰

The steadygrow program is specifically addressing the need for weight monitoring and feedback which I consider to be a vital part of the “eat healthily and exercise well to stem the obesity epidemic” message.  It does not provide specific detailed diets or exercise programs but instead informs parents of the options and encourages them to follow their country's Healthy Eating Healthy Activity guidelines¹¹ and make small but significant changes that they can practice and maintain over the long term (eg changing to low fat milk) rather than have them focus on short term, difficult to implement solutions.

Pediatricians already have their hands full dealing with children who have severe obesity.  There are issues with regard to family doctor access in parts of New Zealand, and an Australian audit has highlighted the fact that family request for weighing and measuring may be positively associated with family doctors becoming involved in this area of health management.  There are also significant issues about the stigmatization of obesity which support the need for parents to have private, secure access to information about this condition as it relates to their family.  In all of these areas steadygrow makes an important contribution.  Most importantly though, it empowers parents to take control of the things that they can in terms of supporting their own children’s good health, and it encourages them to understand the issue at a deeper level so that they can be informed participants in community debate and community efforts to help all children to better health.

Dr Felicity Breen.

24 June 2008

1. Lazarus R, Wake M, Hesketh K and Waters E.  2000.  Change in body mass index in Australian primary school children, 1985 – 1997.  Int J Obes Relat Metab Disord.  24: 679-84.
2. National Health and Medical Research Council of Australia: Clinical Practice Guidelines for the management of overweight and obesity in children and adolescents. 2003
3. Ibid. P. 4.
4. Campbell K, Waters E, O'Meara S, Kelly S, Summerbell C. 2006 Interventions for preventing obesity in children. Cochrane database of systematic reviews 2003. (updated 1 Aug 2005)
 5. Schleimer K. 1983.  Dieting in teenage schoolgirls. A longitudinal prospective study. Acta Paediatrica Scandinavica Supplement, 312:1-54.
6. Patton GC, Johnson-Sabine E, Wood K, Mann AH, Wakeling A. 1990.  Abnormal eating attitudes in London schoolgirls-a prospective epidemiological study: outcome at twelve month follow-up. Psychological Medicine.  20(2):383-394.
7. Killen JD, Taylor CB, Hayward C, Wilson DM, Haydel KF, Hammer LD, Simmonds B, Robinson TN, Litt I, Varady A. 1994.  Pursuit of thinness and onset of eating disorder symptoms in a community sample of adolescent girls: a three-year prospective analysis. International Journal of Eating Disorders.  163:227-238.
8. Gerner B, McCallum Z, Sheehan J, Harris C, Wake M.  2006.  Are general practitioners equipped to detect child overweight/obesity?  Survey and audit.  Journal of Paediatrics and Child Health.  42(4): 206-211.
9. Higgins PB, Gower BA, Hunter GR, Goran MI.  2001.  Defining health-related obesity in prepubertal children.  Obesity Research.  9(4): 233-240.
10. Batch JA, Baur LA. 2005.  MJA Practice Essentials – Paediatrics:  Management and prevention of obesity and its complications in children and adolescents.  Medical Journal of Australia.  182(3): 130-135.
11. NZ Ministry of Health.  Healthy Eating – Healthy Action.  Oranga Kai – Oranga Pumau.  A Background 2003.