Elsie Taveras, MD, MPH: Tackling Childhood Obesity

Q: From a young age Dr. Elsie Taveras who grew up in a family of Dominican immigrants in the Bronx saw firsthand the challenges in the healthcare system, especially for underprivileged and marginalized communities. This became one of the defining factors leading her to a career as a pediatrician. In her research Elsie focuses on childhood obesity. Her work seeks to not just understand the determinants of obesity in women and children but also explain why and how those racial and ethnic disparities exist in obesity. Elsie’s findings have changed how clinicians understand and treat childhood obesity. In fact, the Robert Wood Johnson Foundation identified her work in early life origins of childhood obesity as one of the most influential studies of 2010. Today, Elsie leads Mass General’s Division of General Pediatrics and serves as the Executive Director for the Kraft Center for Community Health at Mass General. So, welcome, Elsie.

A: Thank you for having me.

Q: So Elsie, I know you have spent a lot of your career studying childhood obesity, I’m wondering if you can just talk a little bit about the rates of childhood obesity and how have we gotten here.

A: Almost all of the statistics show that in the United States today about a third of children and adolescents have overweight or obesity.

And I started my pediatric training right around the time when we were seeing a very rapid increase in the rates of obesity in the United States. More recently we have seen a leveling off of obesity, especially among the youngest of children who are about two to five years of age, but that leveling off hasn’t been the same for adolescents and adults.

And so despite years and years and years of studying the problem and understanding the trends and understanding the determinants and origins, we still have obesity rates that are historically high, particularly for children and adults, and still have quite a bit to improve upon the high prevalence of obesity in the U.S.

Q: And what’s going on?

A: I think everybody will say that the origins of obesity are multifactorial. When I first came to Boston to do my pediatric residency training, I had always been interested in trying to focus in an area where there were health disparities. And I had my outpatient pediatric clinic in Roxbury, in the middle of Boston. I say to everybody that had my family landed in Boston, my family would have been the type of family that I was caring for.

As a resident I kept seeing this what I eventually called the triad of the inner city poor. Almost every single one of my pediatric patients had asthma, had obesity and/or behavioral health conditions. And around the time that I was finishing my residency training I was going to go back to get my Master’s in Public Health and really wanted to start thinking about the approach to how to think about health disparities and particularly health disparities in a condition that was of high burden in low income populations.

And realized that for obesity, and this is now about 20 years ago, we had no idea what was causing the rapid increases that we were observing, very little in the way of effective interventions in clinical settings, in community settings, and it was a perfect opportunity to really inform the science, both in epidemiology but also to do what I later did which is try to use some of that epidemiology to inform our interventions.

It’s, to this day, difficult to pinpoint even one or two things that have led to the rapid increase in obesity. I think it’s very clear that it’s a combination of dietary factors, physical inactivity, poor sleep, and a number of environmental factors that affect the way we live that are contributing to the high rates of obesity.

Q: Why do you think it hadn’t been studied until fairly recently?

A: Well, I think 20 years ago we were right in the middle of that rapid increase in obesity in the United States and we have progressively seen continued increases in adults and adolescents and school age children.

Obesity is very difficult to treat, and much of the work that was happening in obesity 20 years ago, and up until very recently, has very much focused on how do we treat the condition once it’s present, and not enough happening to design and think about solutions for prevention.

Prevention of obesity is a whole lot easier than treatment. One of the things that has been different, particularly over the last 10 years, is a greater emphasis on prevention. And particularly for the work that I’m interested in, prevention that begins very early in life. And so I think that what we are starting to see is a bit more emphasis on prevention than focusing only on treatment, and much more emphasis and focus on early life in pregnancy and early childhood than focusing on late adolescence and adulthood.

Q: It’s interesting, it seems to me that it used to be that maybe prevention we sort of think of as a different industry. The gym industry and the fitness industry is about prevention, whereas medicine is where you go once you have a problem. Is that shifting?

A: Well, I think we’re starting to think of prevention and how that happens essentially in every single setting where children spend their lives. They spend their lives obviously at home and school, in their communities, in playgrounds, and see their physicians fairly infrequently, thankfully, if they are healthy. And so I think because of that our focus on prevention is taking us outside of the clinical setting where treatment occurs.

And it is taking us to childcare settings, to schools, to community settings, and really thinking creatively about how do we bring prevention efforts out of the clinical setting where we can deliver a much lower of a dose than we can if we were to get out of the clinical setting for prevention.

Q: Can you talk about some of those interventions? Or when you go into a childcare center what does that look like? What are you doing?

A: So, I should say I’m a pediatrician and I think by my natural inclination when I finished residency was to think about what can we do in the clinical setting, and much of the early work that I did and that I was fortunate to do with a research team at Harvard Medical School and the Department of Population Medicine, was to try to understand what we can do from a pediatric primary care perspective to work to prevent and manage obesity in that setting.

And then little by little, and I should say that some of that too was influenced by funding sources, so the NIH and other federal funders and foundations were very interested again in kind of a treatment paradigm, what can we do from a clinical perspective to prevent and manage obesity.

So, there were outside forces and my own kind of inclination as a clinician to think: what should we be doing in primary care settings and in the clinical setting? And then little by little that has changed. There is more emphasis, as I mentioned, on prevention and efforts outside of the clinical setting, and that has led my team and many others across the country to start thinking about going to where the children are and thinking about how do we design interventions that can happen in families’ homes and how do we design interventions for childcare and in schools.

One of our most recent interventions was a study called Healthy Habits Happy Homes where we actually recruited families, low income families in the greater Boston area, to try to teach parents of young children, preschool age children new routines to prevent the start of unhealthy weight gain in their children.

And so in some of the studies in Happy Homes and in others what we do is essentially retrain parents to understand what are some routines that they can implement in their homes to prevent unhealthy behaviors like bedtimes at 11:00 at night, like sugar sweetened beverages in those lunch boxes, like fast food instead of meals prepared at home.

Another recent intervention we have been testing is a program called “Box” where it’s a structured physical activity program before the start of the school day in a number of public schools both locally in Massachusetts but now nationally and even internationally.

And that program is showing that children who participate in these structured physical activity programs an hour before the start of the school day, it wards off obesity, it wards off unhealthy weight gain. So it’s just a couple of examples of how we’re really pushing ourselves to get out of our comfort zone which is really the clinic and really taking us to places where children spend their time.

Q: Yeah, so kind of hitting the streets with your ideas.

A: Yes, that, that for sure is very familiar to me. I feel like hitting the streets and getting out of brick and mortar clinical facilities has been something I have done for the last 20 years or more actually, even during medical school, really thinking about how do we shift our approach to get into the community and into the environments where behavior change is happening, and trying to influence what’s happening in these disadvantaged settings and conditions to improve health.

Q: You mentioned, Elsie, the disadvantaged settings. What is different about being in that setting versus somewhere else? What is it about that setting that might put you at greater risk or you have more challenges?

A: I’ll give you an example that I have shared in the past is that I can counsel a parent of a six year old to improve their child’s physical activity, to eat healthier foods, to get their child to sleep at an appropriate bedtime, but if that parent goes back home to an environment and a community where the playgrounds are unsafe, where there is a lot of crime that prevents them from going for a walk in the early evening, if they are getting their groceries from the local corner store instead of a large supermarket, if they are living in a housing development where there are neon lights right outside their child’s window for safety reasons and those lights are preventing that child from getting an appropriate amount of sleep or high quality sleep those are the types of factors that are almost entirely out of that parent’s control.

And I think it’s unfair sometimes to expect that this, that the behavior change that has to happen to improve obesity or to prevent obesity, it’s unfair to think that all of that falls on a parent. Much of it in, especially in the patients that I have cared for, has really been because of the communities where they are living in, or at least influenced to a large extent by their surroundings and their environments.

And so, for quite a bit of our interventions we focus on individual parenting and, in addition, we try to arm families and parents with tools and suggestions about how to combat those environmental pressures and influences, which I think is so important for obesity prevention.

Q: What does that look like?

A: Well, for one thing we try to actually get families out of their immediate environment. I have to tell you, this was true for me, I grew up in the Bronx and my family had a business in Washington Heights, so outside of the Bronx and Washington Heights, I didn’t really know New York City. I don’t think I ever ventured into Queens or Brooklyn.

And the same happens here. Community and our sense of community is very local. One of the things that we have tried to do is actually pull families to explore the broader community around them. I would say that for some of my families in Boston their community is maybe five blocks around them. And so some of the things that we have done is to encourage the exploration of local rec departments and local farmers markets.

And so some of the things that we have tried to do in addition to increasing awareness about the larger community and resources in those larger communities is also trying to think about how to do that on a budget. We have done a lot of exploration on what are the local deals in the supermarkets that can improve a family being able to eat meals that are prepared in the home instead of going to fast food restaurants.

We’ve done comparisons of frozen fruits and vegetables instead of sometimes the high cost of fresh fruits and vegetables, and done that comparison and price for families.

Q: Yeah, I think it’s easy for people to say, “I can’t afford to shop at Whole Foods. I can’t buy organic food” and shut down, but if you start to understand there are, it’s a spectrum and there is other options, and there is the Y or there is the Esplanade.

A: Right, exactly. And I have to say sometimes it isn’t even cost related. I think sometimes it’s just awareness. So, I didn’t know what a leek was until I was in medical school. I never ate leeks. I never ate Brussel sprouts. It wasn’t part of my culture. It wasn’t part of my Dominican diet.

And I think we have found also that there is this need for improved nutritional literacy and introducing families to foods that they wouldn’t necessarily have tried and they wouldn’t necessarily purchase certain foods if they are on a budget, right?

So I’m not, if I am a family of four and I have a limited budget I’m not going to try something that might go to waste or that my children won’t eat. And so in some of our interventions, we have done taste tests and we have introduced families to different types of foods that they wouldn’t necessarily try on their own and broaden kind of nutritional literacy.

Q: I’m curious, Elsie, it sounds like one thing that you’re doing is pushing people a little outside of their comfort zones to try new things or see new things or go new places. Has there been any pushback?

A: So, I think we definitely nudge.

We were talking earlier about trying to wean ourselves off of sugar. It took me a long time to drink coffee without sugar. I grew up with my café con leche and café con leche with sugar. And so I think behavior change is hard for everyone, and it’s not so much pushback. It’s just that change is hard and takes time to actually become our everyday behavior. It’s more just our own natural tendency to not want to change a behavior that we have gotten so used to.

Q: that makes a lot of sense. You know, when you think of the socioeconomic spectrum and people at the lower end, you think of people in the cities, but there is also the rural poor, they might be at the same level, but they have very different lives. And do you see the same trends when it comes to things like health and obesity?

A: So, I think that the biggest difference in some of the U.S. studies that have focused predominantly on families in rural settings is just the lack of ability to have the resources for physical activity and access to foods.

We have done some studies showing that that, just the mere distance from a supermarket or the ability to have sidewalks, if you’re living in a rural setting really does influence behavior change for those families in rural settings as well.

Q: And what about things like lifestyle, so beyond just do you exercise, do you eat well, but how far do you have to go to work, what kind of hours do you have to work, where are your children during the day? Is that a piece of the puzzle?

A: Well, I think a piece of the puzzle that has been less talked about but emerging as an important factor is sleep.

So, we focus a lot on diet and physical inactivity, but we rarely talk about the influence of sleep on weight gain, and there is quite a bit of research in adults and even some of our own research that we have applied to children, that shows that independent of our nutrition and our physical activity, that children who get insufficient sleep are at greater risk of unhealthy weight gain.

Q: When you’re talking about sleep, I feel like it’s one of those topics that has been in the media, and there is lots of news stories and Arianna Huffington is all about sleep, is that helping that it’s kind of in the zeitgeist of the communities that sleep is good?

A: So, I think it can only help. I can tell you that what we tend to see in the media and social media and the awareness that is increasing has not made it to some of the populations that I care for. It has not reached the low-income populations, and I think that we’re trying to include it more and more in some of our studies and interventions, because I can’t tell you how often in those settings when I’m out late or in the hospital late that I see two year olds that are up at 10:00, 11:00 at night.

And so I think the message around sleep, it’s important and I’m happy to see the increasing awareness and in the media, but I don’t think it’s reached certain audiences. And so all the more reason to try to get the message out equitably so that those messages around the importance of sleep can be beneficial for the entire population.

Q: How does pregnancy relate to early childhood obesity?

A: I mentioned that when I first started working in the area of obesity, much of what I was doing was actually epidemiology. And I had the good fortune to work on a cohort of women that were recruited during pregnancy. And the women and their offspring were followed and actually have been followed for the last 16 years.

And as fortunate that I was able to work in a research team that was actually trying to explore what were some of the early origins of obesity. What are the determinants and risk factors, even when a woman is pregnant, that increases her offspring’s risk of obesity?

Some of those are gestational weight gain and excess gestational weight gain during pregnancy, gestational diabetes, some nutritional factors during pregnancy. And then after infants are born, infants who are formula-fed instead of breast fed, infants who are introduced too early to complementary foods, and certain dietary and lifestyle factors even in the first two years of life can predict unhealthy weight gain in children.

It’s kind of this common myth, right, that during pregnancy we should be eating for two and that chubby baby is a healthier baby. And I feel like what I did for the first 10 years as a junior faculty was trying to debunk that myth a bit.

And so what I also find myself fortunate to have had the opportunity to do was not just to work in this cohort study that I mentioned to understand and perform the epidemiology on risk factors, but then more recently designing interventions to target those risk factors.

Q: You mentioned breastfeeding, which is a simple biological process, but it can be really challenging, especially for a mom if she is working and working long hours. Is that something you have done work around to help make it more sustainable?

A: Breastfeeding is surprisingly complicated, and I remember, so we have done a number of different studies showing that infants who are breastfed have a healthier weight trajectory, and that is for a number of different reasons.

Infants who are breastfed naturally learn how to self-regulate how much they are feeding and there are also properties of breast milk that are different from properties of formula that seem to be protective, at least in the short term. I think it’s incredibly challenging for some women to nurse, especially if they have to go back to work or if they have the demands of work or school.

I remember, many years ago, as we were trying to design interventions to improve and increase the duration that women were nursing their infants. We did a number of focus groups with low income women and working women to try to understand what were some of the things that we could do to improve their rates of breastfeeding.

And I remember one woman in particular who told us, “You know, we keep hearing that this is, this should come naturally, that this should be easy, that this is something that women have done since the beginning of time. And what they don’t tell you, what the doctors don’t tell you or the nurses don’t tell you, is that our breasts don’t come with instructions.”

That actually became part of one of the educational materials, that we created for women in the nursery was that breasts don’t come with instructions, and actually sometimes even in the same family nursing can come very easily for one child, but then the second child turns things completely around. Thinking about how do we support women without kind of the pressure of “you should know what you’re doing, you should know how to do this.”

There are a lot of reasons why women choose not to breastfeed that we shouldn’t judge or stigmatize, and I think it’s becoming equally important that we learn how to support women who for whatever reasons they have have chosen not to nurse and have chosen to feed their babies infant formula. And some of the things that we have started to do, even in our own work is trying to develop strategies for those women who can’t or choose not to nurse.

Q: So, support all the choices.

A: Support the spectrum of choices, which I think is important not just for infant feeding but across the board.

Q: And there is different ways to be healthy. It’s not one cookie cutter pattern, it sounds like.

A: Oh exactly, exactly, and really being just as precise with our counseling as we are with the way we would approach any other treatment option.

Q: Elsie, I want to take you back to something you said earlier about when you were entering medicine you always knew you wanted to find a field where you could study disparities. And why was that?

A: So, I grew up, and I mentioned earlier I grew up going back and forth between the Bronx and Washington Heights. I received my own care in Washington Heights. My family grew up right in the shadows of a very large academic medical center in New York City, and I received much of my own primary care in the emergency room or in private settings with local pediatricians before the time when academic medical centers, like we have here, were investing in community health centers and community resources for their growing low income population surrounding their academic health center.

And so, that experience of seeing families like my own needing the resources for improved access to healthcare was one that the ability was there, but it wasn’t until much later that there was an investment in New York City and across the country to increase access to healthcare in community and low income communities.

For me that experience very early on of the lack of access to healthcare in our low income community was one that stuck with me. I then went on to do college and medical school and I trained during medical school at Bellevue Hospital. So, if my early childhood exposed me to the implications and the outcomes that are associated with poor access to care in low income communities, Bellevue Hospital introduced me to how people were essentially trying to hack that lack of access to care.

I’ve never seen a place that was so devoted to thinking about creative solutions to the approach to people living in poverty. And I think it was during my medical school training that I realized that there were creative solutions that could be applied to health disparities and there were creative solutions to kind of combat lack of access to healthcare in disadvantaged communities.

And so I came to Boston with a strong sense of studying a condition and working in settings to improve access to care for low income communities and really thinking creatively about how do you bring to bear all of the resources available and creatively think about how to design interventions for disadvantaged populations.

Q: Based on the things you’ve been talking about, it strikes me that I think often we think of health as this very personal thing and the decisions that I make about my health, and that there is almost, sometimes it feels like there is a moral component to it, if you’re making the “right” decisions. Do you think there is sort of a shift that we need to make in our thinking of it as more of a community issue rather than a personal issue when it comes to health?

A: I think it’s become increasingly clear, and I have to say as a pediatrician this is quite familiar, children are maximally dependent on their parents and their environment, and I think as a pediatrician we’ve always recognized that the health of children is so much determined by their environments.

And so the whole aspect of social determinants and how our health is influenced by external factors that aren’t always under our individual control is something that is very familiar to pediatricians.

It’s now becoming much more part of the national discourse and national awareness that it’s not just for children, that for adults and for populations, especially low income populations, it’s becoming increasingly clear that much of the health is so much more determined by where they live, their zip code, access to food, access to healthcare, than sometimes their own individual behaviors.

And that means taking a very different perspective to the way that we approach health and providing healthcare, that it’s not necessarily individual behavior change; it’s really trying to improve those factors, those social determinants that are influencing health.

It sometimes means that we’re prescribing a prescription for children to go to their local WIC program to learn about food packages, to improve the quality of their diet. It sometimes means helping a parent of a child with asthma to improve their housing conditions if they are living in housing that is exacerbating their child’s asthma.

I think we have learned for quite some time that we have to go outside of our traditional medical approach to think about what some of these social factors and environmental factors are that influence health and try to think of what the prescriptions will be for some of those things.

Q: So, when you take stock of sort of how far you have come and where we have gotten as a society do you feel hopeful?

A: I feel incredibly hopeful. I feel particularly fortunate to be in an institution that values community health and to be in a place where our leadership has risen the status of community health and has made it part of our mission to think about the health of our neighboring communities.

I am in very good company here at Mass General, and that’s I think what makes me hopeful is the fact that I know that improving the health of communities, not just as part of my role at Mass General but particularly my role in the Kraft Center has made me quite hopeful that there are institutions, there are leaders and people out there who feel just as strongly about improving the health of low income communities as I do, and that makes me quite hopeful.

Q: Great. Well, thank you so much, Elsie. It’s been a pleasure to talk with you and to learn a little more about community health. Before you go I have my final five questions. Ready?

A: Ready.

Q: What is the best advice you have ever gotten?

A: The best advice I ever got was when I was a pediatric resident and I was advised not to complain, that everyone was in the same boat, and that just because I was sleep deprived and tired that so was everybody else. No one likes a complainer, especially when everybody is in the same boat. I think that is the one that I remember so vividly is that, yeah, is that approach to my work ethic is to always approach it in a positive way.

Q: So the name of this podcast is Charged, what does that word mean to you?

A: Charged. I think when I hear charged I think energized, I think motivated, I think empowered.

Q: How do you recharge?

A: Well, I get, try to get eight hours of sleep. I try to be physically active. I try to meditate and take some time to kind of recharge in those ways.

Q: And when and where are you happiest?

A: I am happiest with my family, with my children and my husband.

Q: And last question: What rituals help you have a successful day? A: Well, I do try as much as I can to get eight hours of sleep. It’s sometimes hard and I don’t always get that. I try to be active during the day. I try to take breaks, multiple breaks during the day to get up and walk. My Apple Watch helps me with that. I try to drink a lot of water. I don’t drink any sugar sweetened beverages. I try to make sure that in all of my meals there is at least one fruit or a vegetable. I try to practice what I preach.

Q: Well, that concludes our time. Thank you, Elsie. It’s been such a pleasure.

A: Thank you.