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Dr. David Ammend, MD

Dr. David Ammend, MD

by Dr. David Ammend 

As a general pediatrician by training, I have been taught to try to look at children as a whole when attending to their health needs.  In my role as Medical Director of Northwest Passage residential treatment programs over the past 18 years, my practice has been focused on the health of children with a very particular set of problems, and there can be a tendency for me to pay insufficient attention to children’s general health as we are sometimes faced with a child and family in extreme distress due to mental illness.  However, my ability to keep the “whole child” in mind has been sharpened by the growing recognition that it is exactly the issue of “lifestyle” in its broadest sense has a profound impact on mental health.  Here I would like to discuss some of the challenges that anyone involved with the care of children face when trying to promote a “healthy lifestyle”.

Over the past 5-6 years I have been working with some of my Northwest Passage colleagues to better understand the role of a healthy diet and physical activity in promoting mental health, and to use that knowledge to inform our work with the kids we serve.  What has become increasingly clear to me over that time is that there is a large and growing body of scientific evidence that one’s lifestyle – and in particular one’s diet and level of physical activity – can have a significant impact on both the maintenance of mental health and treatment of mental illness.  I have been pleased to see evidence of a growing recognition among health care professionals and the lay public that these factors are connected.  Sadly, I have also witnessed a seeming glacier pace of tangible progress in the society-wide promotion and achievement of healthier lifestyles for our children.

As a measure of the slow response of our institutions, I believe that a look at the reality of the progress achieved by our schools in the areas of nutrition and physical activity is instructive.  I do not mean here to “pick on” our schools, nor do I wish to paint all schools with the same (largely negative) brush.  But overall the evidence shows that by-and-large our nation’s schools have done a poor job of promoting healthy living.  To those who would say that we already ask our schools to do too much, and give them too much blame, I would say that in general that may be true.  However, when it comes to fundamental lifestyle issues like diet and exercise, I don’t see how we can achieve better health for our kids WITHOUT including the schools, given that kids eat 1 or 2 meals per day (plus snacks) and spend nearly one half of their waking hours 5 days/week for 9 months of the year at school.

Why aren’t our schools providing better nutrition and requiring more physical activity?  Perhaps the issue is lack of funding – we all know (or suspect) that healthier food costs more.  And there is the concern about standardized test results.  Surely we cannot afford to waste time in physical education classes when there is preparation for testing to be accomplished.  Both of these points would suggest that it is a lack of public support for a larger school role in these areas that stands in the way of progress.  But the facts – at least in my part of the world – do not support that assertion.  An August 2013 public opinion poll undertaken by Public Opinion Strategies as part of the Transform Wisconsin project showed that in Polk County (my home county):

  • 96% of respondents agreed with the statement “Ensuring kids have daily physical activity in schools will help improve their academic performance.”
  • 84% favored “requiring 60 minutes of daily physical activity for kids during the school day.”
  • 80% said that they would “pay more to ensure locally grown Wisconsin fruits and vegetables are served in our schools.”
  •  85% agreed that we should “require schools and state and local governments to buy and serve some locally grown Wisconsin fruit and vegetables.”

Clearly physical activity and healthy food are seen as important, and the public supports a stronger role for schools in delivering these “public goods”.  Yet our local school districts have not fully embraced the principles being advanced here.  While there are variations in the extent to which our area school districts promote healthy living, overall there remains much to be done.  In other words, public opinion and practical outcome do not seem to mesh when it comes to the promotion of healthy diet and exercise in our schools.

How can something for which there is strong evidence of benefit and popular support fail to take hold and engender huge changes in individual and social behavior?  To understand this, it is instructive now to examine our own experience here at NWP.

My work in this area was initially spurred by the childhood obesity epidemic that received much press in both the medical community and the general public beginning more than a decade ago.  Our focus at NWP was aimed at identifying overweight and obese residents and attempting to intervene through changes in diet and exercise.  The “end point” of our intervention was weight loss.  At that point we appreciated only an indirect connection between lifestyle factors and mental illness:  For example, a child who is overweight might be more prone to suffer teasing and hence be prone to anxiety or depression.  With more research in this area we began to appreciate that diet and exercise can play an important direct role in the treatment of mental illness.  Later came the recognition that these factors play a critical role in “total brain health” – learning, the maintenance of mental health, and the treatment of mental illness.  We also learned that many children who are not overweight suffer from poor diet and insufficient exercise.  Our institutional focus changed from overweight kids to all of our residents, with our new “end point” being a healthier diet and increased exercise in itself, with the belief that these are likely to benefit every child we serve in terms of total brain health.

And here is where I am to report the smashing success we have had in converting every child we serve into a fresh-fruit-and-vegetable-devouring, marathon running, healthy-lifestyle-preaching promoter of the wonders of clean living.  And, further, that each child is now at the top of his or her class in school, and no longer needs the benefit of the mental health treatment community.

Perhaps you should sit down before you read any further.

The sad, but hardly surprising reality is that we have seen no such thing.  While we have many kids who embrace every hike, basketball game, and weight training session we can offer, there are others who simply have no interest in getting up and running around.  Similarly, while many of our residents rave about our menus and can’t get enough of the fresh fruits and veggies, others feel that they will barely survive until they can get back to the “real food” of their past – the kind that comes from a box and goes straight to the microwave.  Even more frustrating is the fact that – despite hard work and good intentions – our own dietary plans and activity schedules do not yet reflect our own goals.  As I asked about our schools, how can it be that we have not made the progress we desire even though the agency from top to bottom has endorsed the program?

I think that the simple answer to this question, whether we are talking schools, child care facilities, or even individual family homes, is that a broad change in lifestyle is hard to effect.  How many times at the New Year have I vowed to do this or that to get healthier, then had my resolution flag?  Effecting basic changes, especially on a social or institutional level, is very challenging for a variety of reasons:

  • Financial pressures:  The truth is we could not afford to add the cost of resources required (staff and facilities) to make the changes we would like in one calendar year.  We have needed to build these things into our budget, and that process continues.
  • Competing internal goals:  When we attempt to build time into our days for increased physical activities and for more elaborate meal planning and execution, that time has to come from somewhere.  That “somewhere” often involves programming that has deeply entrenched programmatic value that is not easily tossed aside.
  • “You can lead a horse to water but you can’t make him drink.”  Or, you can lead a child to a salad bar, but you can’t make him eat arugula.  In fact, our experience shows that there are MANY children for whom a radical change in diet (say, from one dominated by fast food and soda pop) is not simply a “new experience” but instead is truly a source of emotional distress.  One often needs to move gradually.
  • Different expectations of staff, kids and parents.  Not everyone shares our vision.  We work to promote it, but we need to balance a lot of competing pressures as to what is “ideal,” and feel the need to have our umbrella big enough to include all children and families (and staff) that participate.

I think that the same principles apply to schools, and even to individual families.  And I further believe that those challenges are enough to de-rail efforts to “get healthy” despite the best of intentions.

I fear that what I have written may lead the reader to a sense of futility.  That is not my intention, nor my own conclusion.  But how do we proceed?  The key, I believe, is to take the long view on this and not throw in the towel if there are no quick results.  Keep in mind the notion that this is not an all-or-nothing proposition, and instead focus on building on successes.  One needn’t toss out all of one’s old habits in one felled swoop in order to work for positive change.  There are many ways to skin this cat, but I offer the following as one approach:

  • Work to educate yourself:  The information available on this general topic is vast, to the point that it can be overwhelming.  Type “healthy living” into your browser and see how many hits you get.  If you are new to this area, I recommend the following as an introduction to the topic of healthy living, mental health, and schools:
    • Spark, The Revolutionary New Science of Exercise and the Brain by John Ratey, MD (2008).  Dr. Ratey is a psychiatrist whose work on physical activity and mental health includes an inspiring case study of a school district that has made the commitment to physical activity as a key part of its programming, with well-documented positive results on learning and mental health.  About $10 on Amazon.
    • Institute of Medicine 2013 report Educating the Student Body:  Taking Physical Activity and Physical Education to the School.  This report is long and sometimes daunting, but there are excellent summaries of their goals, research findings, and recommendations.  Those wanting more details can find those in the report, as well as references to many other sources.  This can be downloaded free from the internet.
    • When it comes to actually working with your child/student/client, pick a simple starting point and begin:  For exercise, find something that the child already likes to do.  If it is walking, find a way to get him or her walking.  If it is playing video games, make it games that require ACTIVE participation.  For diet, start by eliminating the worst of the negatives, and do it gradually if that is what needs to happen.  Drinking 8 cans of soda a day?  Drop it to 6 and go from there.  This is a lifetime journey, so take the first step.
    • Don’t expect global changes in a short time, but you CAN see some changes right away.  Our NWP teachers report that simply having kids get up and do some sort of “moving” activity for even a couple of minutes can do wonders for focus.  But there are also benefits that will come only after prolonged commitment to a healthier lifestyle.  Helping the child mold his or her activities and eating over time toward the establishment of healthy habits is the goal.
    • Talk about this.  Talk is cheap, but talk also generates friends, allies, and energy in trying to make larger changes.  Talk to your children, friends, neighbors, teacher, school board, political representatives – anyone.  You never know when you will find someone ripe for action, or someone who already has worked through some of the things that you are struggling with.

In the end, it is my hope that everyone who has an interest in the health of children in general, and those involved in mental health treatment in particular, will find a way to incorporate lifestyle change into their work and parenting.  It is important as in the interest of helping every child to reach his or her full potential, and it is critical as part of the comprehensive treatment of children faced with mental illness.

Feel free to contact me here at NWP if you have thoughts to offer or questions to ask on this topic.  My e-mail address is Davida@nwpltd.org

 

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