1. State your health outcome of interest. (It could be the one you used for week #2 or another one.) Pick two key behaviors that are important factors leading to your health outcome. Explain the importance of these behaviors either for etiology, prevention, or intervention. (If none of the behaviors in the readings are important for your health outcome, suggest another behavior that is.)
One of my main areas of interest is in childhood obesity prevention and management. Two key behaviors that are important factors leading to childhood obesity are (1) poor dietary choices and (2) lack of physical activity.
a. Poor dietary choices: It is well known that poor dietary choices, including the consumption of sugar sweetened beverages and processed carbohydrates, contributes to the development of obesity in children. There are many factors that may lead to poor dietary choices, including the local food environment, commercial messaging, cultural norms, and parental influences. “Food deserts,” or lack of healthy food options in neighborhoods, and “food swamps,” or the over-availability of unhealthy food options like fast food, are more common in high-poverty environments (White, Obesity Reviews, 2007). This geographic disparity may partially explain why low SES adults purchase poorer quality, less healthy food for children, increasing the risk of childhood obesity (Darmon and Drewnowski, Nutrition Reviews, 2015). As for commercial messaging, food companies target children in order to influence immediate dietary choices, condition taste preferences, and build brand loyalty (Lobstein et al., Lancet, 2015). This messaging is often targeted specifically to racial and ethnic minority children or low-income children. Further, parental modeling of feeding behaviors influences the development of childhood obesity. More controlling parenting has been associated with increased snack food consumption in overweight children, and poverty has been associated with more authoritarian parenting (Conger, Child Development, 1994). Finally, what is considered “normal” for a child to eat at one sitting has increased, and there has been a generational shift towards considering a higher BMI as “normal,” which is more pronounced in low-income households (Duncan et al., Childhood Obesity, 2015).
b. Lack of physical activity: It is also well known that a lack of physical activity contributes to the development of childhood obesity. There are many factors that may lead to decreased physical activity, including the built environment, area deprivation, and parental influences. The “built environment” refers to the manufactured surroundings that provide the setting for activity, including buildings and parks, while “area deprivation” refers to an area’s potential for health risk and includes the ecological concentrations of poverty and economic disinvestment. Individuals of lower SES are more likely to live in neighborhoods with less greenery and fewer physical fitness resources, which significantly increases the odds that a child is overweight (Estabrooks et al., Annals Beh Med, 2003; Singh et al, Health Affairs, 2010). In contrast, better neighborhood features, including improved walkability, have been associated with decreased obesity prevalence (Creatore et al., JAMA , 2016). Further, children living in neighborhoods with high crime rates report less moderate to vigorous physical activity (Gordon-Larsen et al., 2000), and even the perception of crime may reduce comfort with using physical activity amenities (Hood, Env Health Perc, 2005). Finally, parental support is positively correlated with physical activity in children (Trost et al, Am J Prev Med, 2003) and low SES individuals are less likely to use physical activity to lose or maintain weight (CDC, 2000)
2. Describe how you would study the role of one of the behaviors described for question #1 and your health outcome of interest. Incorporate a social factor (e.g. race/ethnicity, social exclusion, stress) in the study approach.
I think that further studying the role of cultural norms in childhood obesity is important. While it has been shown that there has been a generational shift towards considering a higher BMI as “normal,” and this shift appears to be more pronounced in low-income households, it would be important to further elucidate if this shift is more pronounced in individuals of different races/ethnicities. More specifically, to further elucidate if the perception of what is considered a “normal” BMI in children is different among various races/ethnicities. To study this, one could first recruit parent-child dyads of various race/ethnicities. Then, the parents could be asked to rate their child’s weight status as being “overweight,” “underweight,” and “healthy weight.” Finally, the child’s height, weight, and BMI could be assessed and an association between the perception of a child’s weight status and their measured BMI could be obtained and compared among individuals of various race/ethnicity.
3. If key health behaviors (e.g. smoking, exercise, nutritious diet) are strongly influenced by neighborhood, income, and/or education, do we need to continue to study how these behaviors influence health outcomes? Why or why not?
It is important to continue to study how key health behaviors influence health outcomes given their vital influence on health outcomes. Studies have shown that behavior patterns are a major influence on health (McGinnis, Health Affairs, 2002). Overall, as a society we devote significantly more resources to treatment than we do prevention. This is especially important to note in the field of childhood obesity, as treatments are often ineffective (especially for children with extreme obesity), and prevention should clearly be a more important focus. Understanding key health behaviors will help us elucidate better prevention strategies for chronic illnesses such as obesity. As key health behaviors are strongly influenced by neighborhood, income, and education, having a better understanding of these social determinants is clearly important for developing better prevention strategies.