A Call to Action for Registered Dietitian Nutritionists and Pediatricians: Reflecting on Physical Activity: Moving Toward Obesity Solutions—Workshop Summary
Over the past several years, the Roundtable on Obesity Solutions has convened experts across a variety of sectors and disciplines to explore the most promising approaches to prevent and treat obesity. Last April, the Roundtable convened a workshop, titled Physical Activity: Moving Toward Obesity Solutions (IOM, 2015), to explore the role of physical activity in the prevention and treatment of obesity. Leading scientists and clinicians explored the science of physical activity and its relationship with obesity. They also brainstormed innovative strategies to promote physical activity as a public health solution to the obesity epidemic. A full summary of the workshop is available online at http://www.nap.edu/catalog/21802.
This workshop revealed a substantial opportunity for both dietitians and pediatricians to reduce the obesity epidemic, one patient at a time. In this perspective, I discuss steps registered dietitian nutritionists (RDNs) and pediatricians can take to integrate active living into their clinical practices.
Call to Action for Registered Dietitian Nutritionists
Physical Activity: Moving Toward Obesity Solutions–Workshop Summary (IOM, 2015) is of particular relevance for RDNs. As nutrition experts, RDNs have a unique knowledge and skill set to help clients optimize food intake. But the scope of practice and expertise should not end there. Everyone in need of a dietitian for dietary advice for weight management also benefits from physical activity counseling and intervention.
A registered dietitian can and should develop a solid understanding of the relationship between physical activity and obesity and incorporate best practices into clinical care.
Physical Activity: Moving Toward Obesity Solutions–Workshop Summary (IOM, 2015) highlighted several key topics of particular relevance for RDNs, which are recapped below.
- Weight loss maintenance is strongly affected by physical activity level. People who lose the most weight and keep it off over an extended period of time are people who are highly physically active, incorporating both light, moderate, and vigorous physical activity into their daily routines. Any counseling or intervention aimed to help people lose weight and keep it off must direct as much attention to exercise as is directed to nutrition to be successful.
- The relationship between physical activity and obesity is bidirectional. That is, low rates of physical activity may contribute to obesity, but having obesity may also contribute to low rates of physical activity. This relationship is observed both in adults and children, even as early as preschool. Realizing this provides even greater urgency for dietitians to include physical activity counseling into any dietary counseling intervention, especially when working with children and families.
- The health benefits of physical activity are pronounced and undisputed, and they also extend far beyond weight management. By focusing on dietary intake exclusively, an opportunity is lost to help a person achieve the many benefits of exercise such as improved learning and cognitive function, cardiovascular health, and mental health.
- Adopting a physically active lifestyle is difficult. The same strategies used to help clients take small steps in changing dietary behaviors also work for decreasing sedentary time and increasing active time. Most notably, an effort towards helping clients develop the skills required to make healthful food choices and implement physical activity into daily life is more beneficial than sharing knowledge, which most people tend to have already.
- The Physical Activity Guidelines for Americans offer a starting point to incorporate physical activity into existing dietary weight management interventions. The guidelines advise that adults get 150 minutes per week of moderate-intensity exercise, or 75 minutes per week of vigorous-intensity exercise, or a combination of the two. Children should get at least 60 minutes per day of activity, with a mix of cardiovascular, muscle-strengthening, and bone-strengthening exercise.
Call to Action for Pediatricians
The panelists at the workshop Physical Activity: Moving Toward Obesity Solutions (IOM, 2015) highlighted the importance of reaching children and families to slow or even reverse the obesity epidemic in the coming years. Pediatricians are uniquely positioned to do this work. Pediatricians see children at all levels of income and access, including those most in need and those who are most at risk for or affected by obesity. And pediatricians see children often, especially in the early months and years when obesity often begins and also when development of gross motor skills sets the stage for later levels of physical activity.
But how does a pediatrician go about doing this in a way that is effective, specific, and supportive of children and their families? Ultimately, pediatricians can take action in these six specific ways to support increased levels of physical activity, which serves as both prevention and treatment for childhood obesity.
- Identify physical activity level. Whether through questionnaires or a brief question in the examination room, get a sense of how often a child is active and in what activities.
- Assess physical literacy, defined by the Aspen Institute (2015) as a child’s ability, confidence, and desire to be physically active. Start to do this by comparing gross motor skill development to age-based norms, and by getting a sense of the child’s interest and confidence in active play.
- Provide specific tools and resources to help families build skills. Refer families to community-based activity programs and other places to be active.
- Encourage parents to be role models and “Not only do as I say, but also do as I do.” Children who grow up in families with active parents are much more likely to be active themselves.
- Advocate. Push for healthy daycare and preschool centers that provide ample opportunities for children to move in ways that they were designed to move—that is, in frequent, short bursts.
- Write an exercise prescription. Include the recommended type of activity, duration, intensity, and frequency.
Of course, doing this is not easy. Pediatricians face many barriers. There is no diagnostic code for physical inactivity or physical illiteracy. There is already not enough time to cover all of the recommended anticipatory guidance topics at well visits. Providers are not generally compensated for the extra time and attention it takes to implement physical activity counseling and an exercise prescription. Plus, exercise prescriptions require referrals, and mechanisms for that are not currently well established. And, like most doctors, pediatricians get little training in physical activity counseling and exercise prescription.
Perhaps as the health care system moves more towards value-based health care and the role of exercise as medicine is better appreciated by payers and providers, doing this work will be easier. In the meantime, evidence suggests that children with overweight or obesity have a greater likelihood of having obesity as adults (Freedman et al., 2005; Whitaker et al., 1997). Thus, there is urgency to start early, when pediatricians can play a critical role identifying increased weight for age and height and helping the child and family change course before an obesity diagnosis is made. But pediatricians also provide important supports for those who have obesity already, including through encouraging physical activity. After all, even if a child never achieves a “normal” weight, he or she still will be able to maintain good health through regular physical activity. But only if he or she takes the first step.
Ultimately, it will take a multifaceted approach across many disciplines to make a significant impact on obesity. In that regard, every health professional should simultaneously address nutrition and physical activity strategies to prevent, treat, and manage obesity. Both dietitians and pediatricians are particularly well situated to do this work: dietitians through their work with clients who are looking to manage their weight, and pediatricians by reaching children early in life.
- The Aspen Institute. 2015. Physical literacy in the United States: A model, strategic plan, and call to action. Washington, DC: Aspen Institute. Available at: https://www.aspeninstitute.org/publications/physical-literacy-model-strategic-plan-call-action/ (accessed July 17, 2020).
- Freedman, D. S., L. K. Khan, M. K. Serdula, W. H. Dietz, S. R. Srinivasan, and G. S. Berenson. 2005. The relation of childhood BMI to adult adiposity: The Bogalusa Heart Study. Pediatrics 115(1):22-27. https://doi.org/10.1542/peds.2004-0220
- Institute of Medicine. 2015. Physical Activity: Moving Toward Obesity Solutions: Workshop in Brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/21760
- HHS (Department of Health and Human Services). 2008. 2008 Physical activity guidelines for Americans. Available at: http://health.gov/paguidelines/pdf/paguide.pdf (accessed January 27, 2016).
- Whitaker, R. C., J. A. Wright, M. S. Pepe, K. D. Seidel, and W. H. Dietz. 1997. Predicting obesity in young adulthood from childhood and parental obesity. The New England Journal of Medicine 337(13):869-873. https://doi.org/10.1056/NEJM199709253371301