Mary Rudolf is not a grandma who feeds chocolate to her three-year old grandson to win his favor.
Indeed, the 68-year old pediatrician, who is also an expert in child obesity, said softly but adamantly, “I do what I preach. I wouldn’t go bananas if someone else gave him a bit of chocolate, but I’d never buy it.”
The Times of Israel interviewed Prof. Rudolf, a soft-spoken immigrant from the United Kingdom, at her son’s apartment in the northern Tel Aviv suburb of Ramat Aviv, where she was babysitting her twin grandchildren on a hot and sunny July morning. During the rest of the week this grandmother is the head of the department of public health at the Azrieli Faculty of Medicine at Bar-Ilan University in Safed, in the north of Israel. The university invited her to be a founding member of the medical school, and she agreed, immigrating from Leeds in 2011.
Sipping tea and picking at a bowl of watermelon cubes, Rudolf explained how a program she developed called HENRY managed to buck the rising trend of child obesity in Leeds, one of Britain’s largest cities. The program, adopted across England for the past 11 years, was implemented aggressively starting in 2009 in Leeds, which became the first city in the UK to report a reduction in childhood obesity.
HENRY’s success was measured in a study by Rudolf and Prof. Susan Jebb at Oxford University and published in the Pediatric Obesity journal in April.
The study showed that over nine years, the number of obese 4- and 5-year-olds had dropped by 6.5%, with a continued downward trajectory. Similar cities in the UK showed an increase in obesity. After the findings were presented at a conference in London in May, news of the achievement made national headlines.
“It’s not often there’s a good news story, and here was the good news,” Rudolf said with a chuckle. “It is possible to reduce obesity, and Leeds had done it.”
The excitement was such that Rudolf, on a visit to London earlier this month, presented her findings to an all-party forum of UK parliament members in London’s Houses of Parliament. There is now interest in making a documentary about the program for national television in the UK.
What and who is HENRY?
HENRY stands for Health, Exercise, Nutrition for the Really Young, but it was also named after Rudolf’s father, Henry, a London accountant.
Rudolf started looking into child obesity while working as a pediatrician in Leeds. Together with a colleague, she decided to tackle obesity in schools and helped set up community clinics to try to stem the growing phenomenon. These clinics, she said, “did wonderful things for the children’s emotional state, but it was very, very difficult to shift obesity.”
Rudolf thus began to think that targeting preschool children, “from zero to five years old,” was a better way to staunch the epidemic, and she set up HENRY in 2007 along with colleague Candida Hunt, a parenting educator.
Factor number one in stopping obesity: Parenting
The program “has a number of important features,” she said, based on research she conducted into what might be relevant for the early years. Rudolf came up with the notion that there are five factors that are important to address. “It is not just diet,” she said.
The first one is parenting. Then comes how one eats, what one eats, physical activity and emotional well-being.
“Of those, I believe that parenting is the most important,” Rudolf said.
Most parents want their children to grow up healthy and try to provide the best for them. However, daily life presents challenges galore, especially for families living in poverty.
“Ideal parenting is where parents can set limits for their children, but also be warm and responsive,” she said, based on research that has been done on the subject.
“Parents who have this authoritative way of parenting are less likely to have obese children,” Rudolf said. But having authority is also “good for everything. It’s good for development, it’s good for their behavior.”
The problem is that “parents aren’t very good at setting limits. They want to be their children’s friend. They want to be very often warm and loving, but they don’t know how to set limits.”
And so parents have to be taught to be tough as well as kind.
“Parents who are very controlling don’t get it right. And those parents who are very warm and loving can be overindulgent. So, the ideal style is to be able to do both,” Rudolf said.
Besides general parenting guidelines, how children eat is key — not only what they eat. HENRY places an emphasis on the importance of eating socially, “sitting down and having meal times, rather than just constantly eating through the day,” Rudolf said.
Physical activity for that age, she explained, is largely about not keeping the child strapped up in a car seat or high chair. “Children naturally are active if you give them the opportunity,” she said.
Rounding out the equation is the emotional well-being of both parent and child: “If people are feeling good about themselves, everything else follows,” Rudolf said.
Thus, the core of the program is about training health professionals and community practitioners to work effectively with parents and their very young children, and teach them the five factors on which to focus.
Traditionally, dietitians, nurses and doctors tell patients what to do, Rudolf said, But HENRY teaches practitioners “to work alongside parents,” listen to them and have parents come up with solutions themselves. “We know that’s much more effective” than preaching to parents, she said.
In the UK over 20,000 professionals have been trained in the HENRY approach over the past 11 years and “it’s been huge,” said Rudolf.
Some of these are people who work one-on-one with families, such as dietitians and nurses. Others are HENRY-trained professionals who work with 12-15 parents at a time, meeting regularly over eight weeks for two hours a week.
HENRY is a nonprofit organization, and individual municipalities can elect to commission it to administer the program, most often in children’s centers set up in disadvantaged areas. All the health care professionals in these centers are trained in the HENRY methods, Rudolf said.
‘Almost universally people think their babies need to eat more than they need’
In addition to the training programs, HENRY also provides tool kits for parents, which contain a guidance chart detailing the recommended portions of food for children.
“Almost universally people think their babies need to eat more than they need,”
Rudolf said. “Too often babies are overfed… and that can result in obesity.”
“We set down the guidelines, which are much less than people think,” she said.
Babies are born with a “natural fuel gauge, they know when they are hungry and when they are full,” which is why breastfeeding is so good, because they stop feeding when they like, and the mother can’t overfeed, she added.
In general, our society expresses love through food, Rudolf said, and children are given rewards that too often are candy or chocolate.
“If you can get things right early on… then the foods we enjoy and we eat as young children are the foods that we continue to eat and enjoy later in life.”
A study published in Pediatric Obesity in 2013 showed that even three months after the conclusion of the training groups, not only were the children eating better and more active, but the program had also positively impacted the parents — and the training practitioners and their children, too.
“They were doing more physical activity, they felt more confident as parents. It was like it was hitting all the buttons. It was very heartwarming to see that this is working,” Rudolf said.
Leeds was particularly successful because Janice Burberry, the director of public health for the Leeds city council, decided in 2009 to have every health and early childhood professional working with preschool children trained in HENRY, said Rudolf. This led to 1,400 practitioners being trained in the program, she said. Over a period of 10 years, 600 parent groups and roughly 6,000 parents received group training.
What was even more exciting about the Leeds study, said Rudolf, was that the decline in obesity happened mainly in low-income families, which HENRY had specifically targeted through its work in the children’s centers in the poorest areas of the city.
Translating HENRY to Israel
Following Rudolf’s immigration to Israel in 2011, the Health Ministry contacted her, seeking to implement the program. HENRY agreed to set up a local team, “intensely” training four women for three weeks and translating and adapting materials to local language and cultural needs.
The program, called Efshari Bari LeMishpacha (“Family health is possible”) has been rolled out as a pilot over five years in nine low-income municipalities with a population of Jewish, Arab and mixed Jewish-Arab residents, including Jerusalem, Ramle, Yeruham and Baqa al-Gharbiya. The program is run by the Health Ministry together with Ashalim, a program under the auspices of the Joint Distribution Committee – Israel (JDC) that deals with youth at risk.
“The whole process was accompanied by a deep assessment by the University of Haifa to measure the impact of the plan,” said Ronnie Hasson, one of the original four Israeli women who were trained in the program, and a member of the Israel team today.
It is possible to reduce obesity, and Leeds had done it
“The data [from the assessment] was very encouraging, with a lot of influence on daily life,” said Hasson.
People cooked more at home, drank more water and ate fewer sweets, she said. In addition, there was a rise in emotional well-being.
The notion, especially among women, that it is important “to recharge your batteries” was internalized well, she said.
It is still uncertain what the next steps for the program in Israel will be.
“The pilots allowed us to learn the challenges and the advantages” of the program, whose national roll-out is now in the hands of the Health Ministry, Hasson said, adding that the health service providers, or kupot holim, of which almost every Israeli is a member, would be the best framework to run the program in.
Meanwhile, Rudolf is due to retire in September. She sees herself continuing to support HENRY however she can, and spending more time with her grandchildren — “a real privilege” — while tutoring her doctoral students who work on projects aiming to correct health inequalities in society and help disadvantaged populations.
Rudolf has also set up a program in Ziv Medical Center in Safed to help prevent injuries in young children. Parents of young children who visit an emergency room are offered a home visit by a student nurse or doctor. The health professional visits the family with a safety kit and checks the home to make sure the home is as safe as possible for young children.
Another program that Rudolf has set up is called Etgar — Hebrew for challenge. It trains medical students to do followup visits with patients at home when hospital staff see there is a need, in order to ascertain they are taking their medications. They also see how the patients are coping in general, and if they need to be put in touch with social services. The program currently operates in four hospitals, in Nahariya, Safed, Poriya near Tiberias, and Nazareth.
“They have now visited maybe more than 1,000 patients,” she said. “We hope this is a way of stopping patients bouncing back into hospital.”
Going back to obesity and the HENRY program, this reporter had to ask: How did you raise your kids regarding food?
Some 30 years ago, Rudolf said, her young family lived in Eilat for four years and then in Haifa for three. So her children were raised generally eating healthy food.
“At that time, there was really only healthy food, you know,” she said. “What could you buy on the streets? Falafel. Falafel is healthy. And children were out playing all the time.”