The family and an obese child

PORODICA I GOJAZNO DETE

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Aneta Lakiü*1


Rezime: Gojaznost kod dece predstavlja „novu“ epidemiju savremenog društva, þiji je znaþaj daleko veüi u odnosu na posledice koje može dati nego samo prisustvo problema. Etiologija gojaznosti je, svakako, kompleksna i multifaktorijelna. U ovom radu se razmatra uticaja porodice na pojavu gojaznosti kod dece i adolescenata u kontekstu Bronfenbrenerove bioekološke sistemske teorije. Kljuþne reþi: porodica, gojazno dete/adolescent, Bronfenbrenerova sistemska bioekološka teorija

Epidemiološki podaci govore o „novoj“ epidemiji – gojaznosti kod dece i adolescenata. Podaci iz istraživaþke studije III nacionalnog istraživanja zdravlja i ishrane u USA (1999) govore da 22% dece i adolescenata ima prekomernu težinu a 11% je gojazno. (1) Prema podacima ECOG (European Childhood Obesity Group), u veüini evropskih zemalja prisutan je trend porasta gojaznosti. Analizom rezultata istraživanja u 22 zemlje u Evropi, kod dece uzrasta oko 10 godina umerena gojaznost i gojaznost prema kriterijumima BMI kg/rrT IOTF kreüe se od 13% u Finskoj do 36% u Italiji, dok je kod nas 16–17% (2). U Jugoslovenskoj studiji prekursora ateroskleroze kod školske dece (JUSAD Studija) kod 6315 dece uzrasta 9–10 godina iz 12 centara u Jugoslaviji utvrÿena je gojaznost prema NHANES I (BMI > P85) kod 20,89% deþaka i 17,25% devojþica, i to umerena gojaznost kod 10–12,5% devojþica i deþaka, a gojaznost kod 7,16% – 8,33% (3). Znaþaj problema nije iskljuþivo usmeren na aktuelno stanje veü, ako se blagovremeno ne tretira, na „noseüe“ probleme za buduünost u smislu ozbiljnih zdravstvenih problema sa hroniþnim tokom. Smatra se da oko 20–40% gojazne dece školskog uzrasta ostaje gojazno i u adolescenciji, a oko njih 80% i u odraslom dobu. „Noseüi“ problemi u buduünosti su, pre svega, hipertenzija, kardiovaskularne bolesti, dijabet (45% novodijagnostikovanih dijabetes tip 2 adolescenata (4)), metaboliþki sindrom. * Prof. dr, Medicinski fakultet Univerziteta u Beogradu, Klinika za neurologiju i psihijatriju za decu i omladinu

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MEDICINSKI GLASNIK / str. 61-67

U daljem toku ovo postaje ne samo zdravstveni problem pojedinca veü ima svoje socijalne implikacije (leþenje, bolovanja, smanjena radna sposobnost). Preterana težina i gojaznost rezultat su jednog disbalansa izmeÿu unosa i potrošnje energije. Težinski status se, najopštije, de¿niše preko body mass indexa (BMI), odnosa težine u kg na kvadrat visine u m (Kg /m2). Treba naglasiti da Centar za kontrolu i prevenciju bolesti (CDC) USA u svojim smernicama ne oznaþava decu kao gojaznu veü koristi termine: „u riziku od preterane težine“, kada deca imaju BMI izmeÿu 85 i 94 percentila za uzrast i pol; deca sa „prekomernom težinom“, kada im je BMI oko/ ili 95 percentila za uzrast i pol. Meÿutim, autori koji se bave ovom problematikom decu þiji je BMI veüi od 95 percentila oznaþavaju kao „ gojaznu“. (1) Ishrana dece i ¿ziþka aktivnost se menjaju u poslednjih nekoliko decenija. Sam problem gojaznosti kod dece i adolescenata nije tako jednostavan kako se na prvi pogled može zakljuþiti. On niti je jednostavan niti jednostran i u kontekstu razmatranja faktora koji utiþu na nastanak ovog poremeüaja svakako je najbolji bioekološki pristup (Bronfenbrener 1986, „Bioekološka sistemska teorija“). (4,5)

ŠEMA (4) Paquette D &Ryan J. (2001), Bronfenbrenner’s ecological systems theory. www.menthalhealth.samhsa.gov


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Ova teorija posmatra razvoj deteta, i svih konsekventnih zbivanja (pa i gojaznost) u toku razvoja u kontekstu sistema odnosa izmeÿu deteta /adolescenta i njegove okoline. Bronfenbrenerova teorija de¿niše kompleks „slojeva“ okruženja, od kojih svaki ima uticaja na razvoj deteta. To su: Microsistem, Mesosistem, Exosistem, Makrosistem i Hronosistem. Microsistem obuhvata odnose i interakcije koje dete ima sa njegovom neposrednom okolinom. Strukture u mikrosistemu ukljuþuju porodicu, školu, susedstvo ili zaštitno okruženje deteta (jasle, zabavište). Na ovom nivou, odnosi imaju dvosmerni uticaj – od deteta i ka detetu (npr. roditeljska oþekivanja i ponašanje imaju uticaj na dete, ali i dete takoÿe utiþe na oþekivanja i ponašanje roditelja). Bronfenbrener ovo oznaþava kao bidirekcionalne uticaje i oni su na nivou mikrosistema jaþi i imaju veüi uticaj na dete. Mesosistem – ovaj sloj omoguüava veze izmeÿu struktura deþjeg mikrosistema (npr. detetovi roditelji i uþitelji). Exosistem – ovaj sloj de¿niše širi socijalni sistem u kome dete ne funkcioniše direktno. Strukture ovog sloja utiþu na detetov razvoj interagujuüi sa nekim strukturama deþjeg mikrosistema (npr. roditeljsko radno vreme, ili porodiþni resursi bazirani na zajednici); dete ne mora biti direktno ukljuþeno u ovaj nivo i ne oseüa pozitivne ili negativne snage koje su ukljuþene sa njegovim mikrosistemom. Makrosistem – ovaj sloj se može smatrati krajnjim slojem u okruženju deteta. Iako nije speci¿þan okvir, ovaj sloj obuhvata kulturalne vrednosti, obiþaje, zakone. Efekti širih principa, de¿nisanih makrosistemom, imaju kaskadni uticaj tokom interakcija u svim ostalim slojevima. Hronosistem – ovaj sloj obuhvata dimenziju vremena jer se odnosi na okruženje deteta. Elementi unutar ovog sistema mogu biti spoljni, kao na primer vreme smrti roditelja, ili unutrašnji, kao ¿ziološke promene koje se dešavaju u toku rasta deteta. Kako dete postaje starije, ono može reagovati razliþito na spoljne promene i može biti sposobnije da bolje odredi kako te promene utiþu na njega. Bronfenbrenerova sistemska bioekološka teorija se fokusira na kvalitet i kontekst deþjeg okruženja. Ekološki okvir Bronfenbrenera, koji govori da multipli faktori utiþu na razliþitim nivoima uticaja ili promovišu ili poboljšavaju rizik za razvoj individue, olakšava razumevanje kompleksne prirode epidemije gojaznosti. Unutar ove paradigme, ponašanje je prepoznato kao rezultat interakcija multiplih supsistema kroz vreme i preko podešavanja, i više je meÿuzavisno nego nezavisno od okruženja. Na održavanje telesne težine individue utiþu brojni faktori na razliþitim nivoima, ukljuþujuüi porodicu, socijalnu zajednicu, i šire društveno okruženje. Ove multilevel faktore okruženja, koji utiþu na pojavu i održavanje gojaznosti, Brownell (4) oznaþava kao „toksiþne“ ili „obezitogene“. Faktori koji potiþu od odluka javne politike i ekonomskih strategija opisuju se kao „uzvodni uticaji“ (Makrosistem). „Nizvodno izgraÿeno okruženje“ ili ¿ziþki

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lokalno (ukljuþujuüi dostupnost podruþjima za rekreaciju i bezbednim pešaþkim zonama, brojnim prodavnicama i pristupnost cena prehrambenih namirnica) – exosistem, utiþu na potencijale individue da postigne energetski balans. Sa druge strane, treba znati da ovi sistemi nisu statiþni veü dinamiþni, unutar sebe i u interakciji sa drugim sistemima; dinamiþni u funkcionalnom smislu, ali i razvojnom. Prelaze iz jednog oblika funkcionisanja u drugi i time daju nove moguünosti brojnih interakcija. U kontekstu ove teorije razmatra se uloga porodice u nastanku gojaznosti kod dece /adolescenata. Porodica je složen sistem sa svojom strukturom i dinamikom. (7,8) Ona je izvorište i ishodište za svakoga u njegovom individualnom razvoju u svakom smislu. Dete uþi širok raspon oseüanja, kao i kako i kada da ih izrazi. U porodici se odvija prva razmena emocionalnih signala; tu je i izvorište ljubavi, ali i osnov i škola za razvoj sposobnosti da se vole drugi i stvaraju bliski odnosi sa njima, da se razvije dobra slika o sebi i da se dobro slaže sa drugima u svakodnevnom životu. Porodica je tu da stimuliše kompletan kognitivni razvoj deteta. Primarne roditeljske uloge su nadzor (kontrola) i nega (briga), s tim da se „standardi“ menjaju u toku vremena–faza razvoja, „odrastanja“ deteta ali i porodice. (7,8) Od kvaliteta tih (prvih) iskustava u porodiþnom okruženju i toga kako roditelji „ispunjavaju“ svoje roditeljske uloge umnogome üe zavisiti i naša svest o sebi, samopoštovanje, sigurnost. Pa, i to da li üemo biti gojazni ili ne. Iako je teško odvojiti šta pripada genetici a šta sredinskim faktorima po pitanju gojaznosti, ipak se može reüi da se, pored biološkog nasleÿa, nasleÿuju i obrasci ponašanja vezanog za ishranu unutar porodice. Prvi deo pripada emocionalnom – kada hrana postaje zamena za ljubav; i „nutkanje“ deteta hranom „izlaz“ depresivnih majki za nemoguünost da daju onoliko ljubavi detetu koliko misle da mu treba ili onoliko za koliko one misle da su bile uskraüene. Istraživanje National Child Measurement programme (NCMP) u Engleskoj za 2010/11, pokazalo je da postoji visok stepen korelacije izmeÿu deprivacije i deþje gojaznosti (multiple, socioekonomske), kao i udruženost gojaznosti dece i niže kognitivne stimulacije. Brojne studije su pokazale da je gojaznost kod dece udružena sa disfunkcionalnošüu porodice; to su porodice gde je pojaþana kohezija, þesti konÀikti, dezorganizacija, odsustvo interesa za socijalne i kulturne aktivnosti, kao i roditeljsko zanemarivanje (9,10) ali postoje i studije koje to ne potvrÿuju. (11,12) Ovo podruþje pripada razvojnoj psihologiji i psihopatologiji. Ali postoje i obrasci ponašanja, vezani za hranu, koji se prenose sa generaciju na generaciju (transgeneracijska transmisija), „van“ psihopatologije i imaju uticaja na nastanak gojaznosti kod dece i adolescenata. Tu se misli na obrasce ponašanja vezane za kupovinu namirnica, kuvanje (masnoüe, vrsta namirnica), uzimanje obroka (uobroþenost ili haotiþnost, zajedniþki obroci, veliþina porcija), ¿ziþku aktivnost, roditeljski odnos prema telesnoj težini (da li sami drže dijete, zdrava ishrana). Porodica utiþe na formiranje ponašanja vezanog za ishranu (ishrana i navike u ishrani). (13,14,15) Dete „nauþi


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da voli“ odreÿene namirnice (navika) od detinjstva. To se odnosi na porodicu. Ali porodica je deo sistema na koji utiþu drugi sistemi. Porodica nije imuna na promene koje diktira društvena sredina. Moderna vremena. Šta nose? Na nivou Makrosistema: U modernom društvu tehnologije su se promenile i postoji velika zabrinutost za zaštitu prirodnog okruženja od ošteüenja koje nose nove tehnologije. Isto se odnosi na socijalno okruženje. Ekonomija je prešla iz industrijskog u tehnološki model, iako su obrasci na radnom mestu realno ostali na etici fabriþkog rada. Moderna vremena nose: urbanizaciju i sledstvene teškoüe za bavljenje ¿ziþkom aktivnošüu, razvoj i korišüenje saobraüajnih sredstava svakodnevno i u sve veüem obimu; napredak visokih tehnologija – TV, kompjuteri; prisutni su novi naþini komunikacije – društvene mreže. Moderna vremena – Šta još nose? Kako se promene u egzo i makrosistemu odražavaju na porodicu i njeno funkcionisanje? Porodica (mesosistem) trpi uticaje egzo i makrosistema. Roditelji oþekuju da rade radno vreme van fabriþkog zvona jer rade u o¿su visoke tehnologije, da imaju odmor u toku radnog vremena, godišnji odmor – ali u praksi nije baš tako; radi se sve više i više, od 9 do 18h (ujutro deca spavaju, uveþe su suviše umorni i roditelji i deca, i zajedniþko vreme „iscuri“). Porodiþni život je u savremenom svetu na poslednjem mestu i žrtvovan je potrebama radnog mesta. Tradicionalna porodica (po svojoj strukturi i funkcionisanju), u kojoj majka najþešüe ne radi, sprema obroke i vodi raþuna o kuüi i o deci i gde postoje zajedniþki porodiþni obroci (ruþak, veþera) sve više je „istorijska“ kategorija. Savremeni ekonomski tokovi i nov (potrošaþki) sistem vrednosti diktiraju novu organizaciju porodice, neophodnost zaposlenosti oba roditelja. Zaposlenost roditelja umnogome utiþe na to kako üe se odvijati i ona osnovna roditeljska uloga brige (nege); u odnosu na ishranu to znaþi – da li üe se uopšte kuvati ili kupovati brzo pripremljena hrana, fast food (snack obroci), šta üe se kupovati (jeftinija nezdrava ili skuplja zdrava hrana), ima li uopšte zajedniþkih porodiþnih obroka ili su svedeni eventualno na zajedniþki nedeljni ruþak (Što se tiþe roditeljske uloge kontrole – Da li roditelji imaju kontrolu nad vanškolskim aktivnostima deteta (TV – koliko i šta gledaju, igrice, društvene mreže, izlasci). Istraživanja u USA u poslednje 3 dekade pokazala su pozitivnu korelaciju izmeÿu zaposlenosti (pre svega majki) i gojaznosti dece i porasta gojaznosti dece u porodicama gde je zaposlena majka jedini roditelj. (16) Ishrana dece i ¿ziþka aktivnost se menjaju u poslednjih nekoliko decenija. Urbanizacija, sa smanjenjem površina predviÿenih za igru dece prepreka je za bavljenje ¿ziþkom aktivnošüu. U školu se uglavnom ide prevozom (odlazak autobusom u školu), sigurnost dece je pod znakom pitanja. Napredak visokih tehnologija – TV (u spavaüoj sobi, koliko sati je dnevno „pred“ TV), kompjuteri, a sa njima video igre i društvene mreže. Rezultat ovog tehnološkog napretka su smanjena ¿ziþka aktivnost i sedeüi naþin života. Istraživanja u USA su pokazala da u naporima da se adolescenti

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ukljuþe u ¿ziþke aktivnosti (posle škole ili treninzi) 1/3 ne prihvata, a 10% tih pokušaja završava konÀiktima, a samo 1 od 5 dece upražnjava neku vrstu ¿ziþke aktivnosti van škole. I roditeljska uloga kontrole – monitoringa nad aktivnostima dece i kvalitetom tih aktivnosti je kompromitovana. Sadržaji koji se nude deci i mladima preko TV-a u velikom delu su reklame; i to- sokovi, grickalice; „fensi“ fast food restorani za decu. Izbor hrane koji se deci nudi je ogroman, a deca su takoÿe jedna velika konzumentska grupa (imitaciono, novo, interesantno). Posebna, nešto speci¿þnija, kategorija što se tiþe gojaznosti su adolescenti. (17) Adolescenti su speci¿þni pre svega u odnosu na uzrasno uslovljene somatske promene (promene „telesne sheme“ usled rasta i razvoja, višak teþnosti i utisak podnadutosti), ali pre svega psihološke promene. Preokupiranost telesnim izgledom i promenama u telesnoj shemi (pre svega u smislu nezadovoljstva novim izgledom koji je najþešüe izvor frustracija, s jedne strane, i jake želje za dopadanjem i prihvatanjem od strane vršnjaka, s druge strane), i depresivnost kao normativna kategorija u adolescenciji faktori su koji olakšavaju (pored prethodno pomenutih) nastanak gojaznosti u adolescenciji. Govorimo o nastanku gojaznosti u sklopu poremeüaja ishrane, depresivnosti. I šta sada? „Opasnost“ je uoþena, kako protiv nje. Pre svega, treba znati da je ovo problem javnog zdravlja i u tom smislu je neophodno organizovati preventivne programe na svim nivoima i svim strukturama i slojevima. Edukacija svih slojeva društva, porodica, škola, mediji. Treba naglasiti da je ovo problem koji zahteva sistemska rešenja i odgovarajuüe ekonomske resurse. Poznat je primer divno planiranog, entuzijastiþki zapoþetog programa zdrave ishrane u školskoj kuhinji u delu Londona (u kome je uþestvovao i Jamie Oliver), ali koji nije mogao da se održi upravo zbog ekonomske neisplativosti. Vlada USA je zapoþela kampanju uvoÿenja zdrave ishrane u školama, koja je propraüena dobrom medijskom kampanjom i uþešüem poznatih liþnosti. Takoÿe, društvena zajednica treba da se više ukljuþi i u omoguüavanje ¿ziþkih aktivnosti dece u bezbednom okruženju (igrališta); zdravstveni sistem (sistematski pregledi, savetovanja), pravni sistem (porezi, cene), javne komunikacije (mediji) – kampanje. Ali, završiüemo jednim naoko intrigantnim pitanjem – da li postoji bumerang efekat – pre svega u odnosu na adolescente – da li insistiranje na zdravoj ishrani, voÿenju raþuna oTT, BMI, broj kalorija može dovesti do porasta poremeüaja ishrane (anoreksija – bulimija tipa) kod adolescenata/ adolescentkinja?(18). Odgovor je: Ne. Baza poremeüaja ishrane jesu psihološki problemi – samo na tom terenu, insistiranje na zdravoj ishrani, ograniþavanju i usmeravanju u ishrani može imati za posledicu razvoj poremeüaja ishrane. Van toga, zdrava ishrana je deo zdravih stilova života. I u tom kontekstu su neophodne aktivnosti na svim nivoima – Microsistem, Mesosistem, Exosistem, Makrosistem i Hronosistem.


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Literatura: Budd G., Hayman L., Addressing the Childhood Obesity Crisis: A Call to Action. MCN, Am J MaternChild Nurs 2008; 33(2): 11-118. Livingstone B., Epidemiology of Childhood obesity in Europe. Europ J Ped 2000,159(13):51434. Jugoslovenska studija prekusora ateroskleroze kod školske dece. Urednik S. Nedeljkoviü, Medicinski fakultet u Beogradu, Univerzitet u Beogradu, CIBID 2006, Beograd, Grafoskop. Paquette D &Ryan J. (2001), Bronfenbrenner’s ecological systems theory. www.menthalhealth.samhsa.gov Williams J., Child Obesity in Context : Ecology of Family and Community. Int J Exerc Sci 2011,4(2):86-92. Perryman M., Nielsen S., Booth J., An Examination of the familys Role in Childhood Obesity, VISTAS 2008 Online. Lakiü A., Poremeüeni odnosi u porodici i njihov uticaj na partnerske odnose. U: Vaspitanje mladih za humane odnose meÿu ljudima i planiranje porodice, Priruþnik za nastavnike, Beograd: Ministarstvo prosvete i Ministarstvo za brigu o porodici Republike Srbije; IP Službeni glasnik:1999; 123-27. Lakiü A., Porodica kao prva spoljašnja realnost adolescenta. U: Unutrašnja i spoljašnja realnost adolescenata, ured.V ûurþiü, Beograd: IP „Žarko Albulj“ 2005; 61-7. ASPE.hhs.gov. Childhood Obesity.aspe.hhs.gov/health/reports Child_obesity/ Banis HT.,Varni JW., Wallander JL et al., Psychological and social adjustment of obese children and their families. Child Care Health Dev 1988; 14:157-173. Lissau I., Sorensen TI., Parental neglect during childhood and increased risk of obesity in young adulthood. Lancet 1994;343:324-327. Beck S., Terry K., A comparison of obese and normal –weight families’ psychological characteristics. Am J Fam Ther 1985;13:55-59. Strauss R.S, Knight J., InÀuence of the Home Environment on the Development of Obesity in Children. Pediatrics 1999;103(6); pp e 85. Mc Bride C., Collins S., Bell C., Quinn C., Lokken Worthy S., Parents InÀuence on Children Weight-Related Behaviors. 2008; URJHS 7. Patric H., Nicklas T., A Rewiew of Family and Social Determinants of Childrens Eating Patterns and Diet Quality. J Am Coll Nutr 2005;24 (2): 83-92. Gibson L., Byrne S., Davis E., Blair E., Jacoby P., Zubrick S., The role of family and maternal factors in childhood obesity. Med J Aust 2007; 186(11): 591-95. Lakiü A., Adolescencija. U: Psihijatrija – udžbenik za studente Medicinskog fakulteta u Beogradu; ur. Jašoviü Gašiü M, Leþiü-Toševski D., Beograd, CIBID: Medicinski fakultet UB 2007. Lakiü A., Poremeüaji ishrane. U: Psihijatrija – udžbenik za studente Medicinskog fakulteta; ur. Jašoviü Gašiü M, Leþiü-Toševski D., Beograd, CIBID: Medicinski fakultet UB 2007; 185 - 8.

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Aneta Lakiü*1

THE FAMILY AND AN OBESE CHILD

Summary: Obesity in children is a “new” epidemic of the modern society, whose importance is far greater in terms of the consequences it creates than is the problem itself. The etiology of obesity is certainly complex and multifactorial. This paper studies the effects of the family on the occurrence of obesity in children and adolescents in the context of Bronfenbrenner’s bioecological systems theory. Key words: family, obese child / adolescent, Bronfenbrenner bioecological systems theory

Epidemiological data suggest a “new” epidemic – obesity in children and adolescents. Data from research studies III of the National Health and Nutrition Research in the USA (1999) show that 22% of children and adolescents are overweight and 11% are obese. (1) According to ECOG (European Childhood Obesity Group), in most European countries, there is a growing trend in obesity. By analyzing the results of the research in 22 countries in Europe in children aged about 10, moderate overweight and obesity according to BMI criteria kg / rRT IOTF ranges from 13% in Finland to 36% in Italy, whereas in our country it is 16-17% (2). According to The Yugoslav study of atherosclerosis precursors in school children (YUSAD Study), obesity was diagnosed in 6,315 children aged 9-10 from 12 centers in Yugoslavia according to the NHANES I obesity (BMI> P85), in 20.89% of boys and in 17.25% of girls; moderate obesity was diagnosed in 10 to 12.5% of girls and boys, and obesity in 7.16% – 8.33% of the children (3). The importance of the problem is not solely focused on the current situation but, if not treated promptly, on the “carrier” problems for the future in terms of serious health problems with a chronic course. It is believed that about 20-40% of obese school-aged children remain obese in adolescence and approximately 80% of them remain obese in adulthood as well. The “accompanying” problems in the future are hypertension, cardiovascular diseases, diabetes (45% of newly diagnosed type 2 diabetic adolescents * Prof dr, School of Medicine, University of Belgrade, Department of Neurology and Psychiatry for Children and Youth.


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(4), the metabolic syndrome). Furthermore, this becomes not only a health problem of an individual, but it also has its social implications (medical treatment, sick leave, reduced working capacity). Excessive weight and obesity are the result of an imbalance between intake and energy expenditure. Generally speaking, weight status is de¿ned by body mass index (BMI), the ratio of weight in kg and height in m squared (kg / m2). It should be noted that the instructions of the Center for Disease Control and Prevention (CDC) in the USA do not describe children as obese, but use the terms such as: “at risk of overweight” when children have a BMI between 85 and 94 percentile for age and gender; children with “excessive weight “ when their BMI is around / or 95 percentile for age and gender. However, the authors who deal with this problem describe the children whose BMI is greater than 95 percentile as “obese.” (1) Child nutrition and physical activity have been changing in recent decades. The problem of obesity in children and adolescents is not as simple as seems to be. It is neither simple nor one-sided and in the context of the factors that inÀuence the occurrence of this disorder, the best approach is the bio-ecological one (Bronfenbrenner’s 1986 – bioecological systems theory). “(4.5)

Graph (4) Paquette D &Ryan J. (2001) Bronfenbrenner’s ecological systems theory. www.menthalhealth. samhsa.gov

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This theory observes a child’s development, and all the consequential events (including obesity) during his growth in the context of the system of relations between the child / adolescent and his environment. Bronfenbrenner’s theory de¿nes complex “layers” of the environment, each of which has an impact on the child’s development. These are: Microsystem, Mesosystem, Exosystem, Macrosystem and Chronosystem. The Microsystem includes relationships and interactions that a child has with its environment. The structures in the microsystem include the family, school, neighborhood, or the child’s protective environment (nursery, kindergarten). At this level, the relations have a two-way impact – from the child and to the child (e.g, parental expectations and behavior have an impact on the child and the child also inÀuences the expectations and behavior of the parents). Bronfenbrenner describes this as bidirectional inÀuences, which are stronger at the microsystem level and have a greater impact on the child. Mesosystem – This layer provides connections between the structures of the child’s microsystem (e.g, the child’s parents and teachers) Exosystem – This layer de¿nes the broader social system in which the child does not work directly. The structure of this layer affects the child’s development interacting with some of the structures of the child’s microsystem (eg, parental work hours, family or communitybased resources); the child does not have to be directly included in this level and he does not feel positive or negative forces that are involved with his microsystem. Macrosystem – This layer can be considered as the ¿nal layer in the environment of the child. Although it is not a speci¿c framework, this layer includes cultural values, customs and laws. The effects of the macro-de¿ned broad principles have a cascading effect in the interaction in all other layers. Chronosystem – This layer includes the dimension of time since it is related to the child’s environment. The elements within this system may be external, such as the time of death of parents, or internal such as the physiological changes that occur during the child’s growth. As the child grows older, he may react differently to external changes and be better able to determine how these changes affect him. Bronfenbrenner’s bioecological systems theory focuses on the quality and context of the child’s environment. Bronfenbrenner’s ecological framework, which says that multiple factors are inÀuential at different levels or that they promote or enhance the risk for the development of individuals, facilitates understanding of the complex nature of the epidemic of obesity. Within this paradigm, the behavior is identi¿ed as a result of the interaction of multiple subsystems through time and across settings, and it is more interdependent than independent of the environment. The maintenance of body weight of the individual is affected by numerous factors at various levels, including the family, community, and the wider social environment. These multilevel environmental factors that inÀuence the occurrence and maintenance of obesity are referred to as “toxic” or


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“obesitogenous” by Brownell (4). The factors that result from public decision-making and economic strategies are described as “upstream impacts” (Macrosystem). The “downstream built environment” or physically local (including the availability of areas for recreation and safe pedestrian areas, many shops and accessibility of grocery prices) – the exosystem, affect the individual’s potential to achieve an energy balance. On the other hand, it should be noted that these systems are not static but dynamic within themselves, and interacting with other systems; they are dynamic in both the functional and developmental terms. They change from one form of functioning to another and thus provide new opportunities for numerous interactions. In the context of this theory, the role of the family in the development of obesity in children / adolescents is analysed. The family is a complex system with its structure and dynamics. (7.8) It is the source and the starting point of each individual in his development in every sense. A child learns a wide range of feelings, and how and when to express them. The ¿rst exchange of emotional signals takes place in the family; it is also a source of love and the educational basis for the development of the capacity to love others and form close relationships with them, to develop a good self-image and get along with others in everyday life. The family is there to stimulate the child’s complete cognitive development. The primary parental roles are supervision (control) and nursing (care), bearing in mind that the “standards” are changing over time and in the development phases, “growing up” of the child and the family itself. (7.8) Our self-awareness, selfesteem, self-con¿dence will depend very much on the quality of the (¿rst) experiences in the family environment and how parents “ful¿ll” their parental role. Whether we are going to be obese or not also depends on this. Although it is dif¿cult, in terms of obesity, to distinguish between genetic and environmental factors, it can still be said that in addition to biological heritage, eating patterns are also inherited from the family. The ¿rst part belongs to the emotional area – when food becomes a substitute for love, and constantly offering the child food seems to be a “way out” for depressed mothers who are not able to give as much love to the child as they think they should or as much as they think they were deprived of in their own childhood. The Research National Child Measurement Programme (NCMP) in England for 2010/11 showed a high correlation between deprivation and child obesity (multiple, socio-economic) and the connection between childhood obesity and lower cognitive stimulation. Numerous studies have shown that obesity in children is associated with family dysfunction; these are the families with a strengthened cohesion, frequent conÀicts, disorganization, lack of interest in social and cultural activities, and parental neglect (9.10,) but there are also studies that do not con¿rm this. (11, 12) This area belongs to developmental psychology and psychopathology. However, there are patterns of behavior related to food that are passed on from one generation to another (transgenerational transmission) “outside” psychopathology and that have

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an impact on obesity in children and adolescents. This refers to patterns of behavior related to grocery shopping, cooking (fat, type of food), meals (regular or chaotic, eating together, portion size), physical activity, parental attitude to body weight (whether they are on diets themselves, healthy diet). The family inÀuences the formation of eating behavior (diet and eating habits). (13,14,15) The child “learns to love” certain foods (creates habits) in his childhood. This refers to the family. But the family is part of the system affected by other systems. The family is not immune to the changes dictated by the social environment. Modern times. What do they bring? At the macrosystem level: In the modern society, technologies have changed and there is a great concern for the protection of the natural environment against the damage caused by new technologies. The same applies to the social environment. Economy has moved from the industrial to the technological model, although the workplace patterns have actually remained at the level of factory work ethic. Modern times bring: urbanization and the consequential dif¿culty in doing physical activity, development and increasing use of means of transport every day, the advances in high technology – TV, computers, together with the new ways of communication – social networks. Modern times – What else do they bring? What are the impacts of the changes in the exo and macrosystems on the family and its functioning? The family (mesosystem) is under the inÀuence of the exo and macrosystems. Parents are expected to work hours after the factory bell because they work in this of¿ce of high technology, to have a break during working hours, a vacation – but it is not really so; they work more and more, from 9-18h (children sleep in the morning, and in the evening both parents and children are too tired, and their time together “leaks”). Family life in the modern world comes last and is sacri¿ced to the needs of the workplace. A traditional family (in its structure and functioning) in which the mother usually does not work, cooks meals, cleans the house and takes care of the children and where there are family meals (lunch, dinner) is becoming a “historical” category. Contemporary economic trends and the new (consumer) system of values dictate a new organization of the family, the necessity of employment of both parents. Their employment greatly affects how the basic parental role (care) develops; in relation to food it means – will the food generally be cooked or will fast food (snack meals) be bought, what will be bought (cheaper junk food or more expensive healthy food), will there be family meals or will they be eventually reduced to a family Sunday lunch? As for the parental role of control – Do parents have control over the child’s extracurricular activities (watching TV – what they watch and how much, games, social networks, going out). Researches in the USA in the last three decades have shown a positive correlation between employment (primarily mothers) and obesity in children and increasing obesity in children in the families where the only parent working is the mother. (16) Child nutrition and physical activity have changed in the last few decades. Urbanization, with the reduction in the surface area provided for children to play is a barrier to physical activity. Children usually drive to school


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(by bus) and children’s safety is at risk; high technology is everywhere – TV (in the bedroom, how many hours a day they spend in front of the TV), computers, along with video games and social networks. The results of this technological progress are reduced physical activity and a static way of life. Researches in the USA have shown that most efforts to engage adolescents in physical activities (after school or training) fail = 1/3 of them reject the idea and 10% of efforts end in conÀicts, whereas only 1 in 5 children practices a kind of physical activity outside school. Even the parental role of control – monitoring the activities of children and the quality of those activities designed is compromised. Much of the contents offered to children and young people on TV is advertising – drinks, snacks, “fancy” fast food restaurants for children. The variety of food offered to children is enormous, and children are also a big consumer group (imitatable, new, interesting). A special and somewhat more speci¿c category in terms of obesity is the category of adolescents. (17) Adolescents are particularly unique in terms of the age-conditioned somatic changes (changes in the “body scheme” due to the growth and development, excess Àuid and the feeling of Àatulence) but primarily due to psychological changes. Preoccupation with the body image and the changes in the body scheme (especially in terms of dissatisfaction with the new looks, which is often a source of frustration on the one hand and a strong desire to be accepted and liked by peers on the other), and depression as a normative category in adolescence, are the factors that contribute (besides the aforementioned) to the occurrence of obesity in adolescence. We talk about obesity within the eating disorders and depression. Now what? The “danger” has been observed, how to ¿ght it? First of all you should know that this is a public health problem and thus prevention programs need to be organized – at all levels and in all structures and layers. All levels of the society, family, school, the media should be educated. It should be emphasized that this is a problem that requires system solutions and appropriate economic resources. A wonderfully and enthusiastically planned program of healthy eating in a school kitchen in a part of London (in which Jamie Oliver himself participated) is very well-known, but it could not be maintained due to its economic unpro¿tability. The Government of the USA started a campaign to introduce healthy eating in schools, which was followed by a good media campaign and the involvement of celebrities. Also, the community should be more involved in providing physical activities for children in a safe environment (playgrounds); health system (check-ups, counseling), legal system (taxes, prices), public communication (media) – campaigns. But we will ¿nish off with one seemingly intriguing question – is there a boomerang effect – especially in relation to adolescents – can insistence on healthy eating, taking care of oTT, BMI, the number of calories lead to an increase in eating disorders (anorexia – bulimia-type) in male/female adolescents? (18). The answer is: No. The basis of eating disorders is in psychological problems – only in this ¿eld, insisting on a healthy diet, setting limitations and giving instructions in the diet may result in the development of eating disorders. Beyond that healthy eating is part of a healthy lifestyle. And in that context

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it is necessary to take actions at all levels – Microsystem, Mesosystem, Exosystem, Macrosystem and Chronosystem.

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