Curbing Childhood Obesity

How can parents halt the creeping epidemic that threatens our kids’ futures? The solution: Change the environment so they can move more and eat well.

In our push-button, remote-control, car-oriented culture—where pizza makes house calls and kids between the ages of 2 and 17 spend more than three years of their waking lives watching TV— we’ve created the fattest generation in history.

Waistlines are widening in people of all ages, but “our children, in particular, are gaining weight to a dangerous degree and at an alarming rate,” warns the Institute of Medicine of Washington, DC, in a new action plan (“Preventing Childhood Obesity: Health in the Balance”) commissioned by Congress to address this growing public health threat. In just 30 years, the prevalence of childhood obesity has soared, with nearly one in three American kids now tipping the scales past healthy weight.

Once dismissed as harmless “baby fat,” childhood obesity is increasingly recognized as a serious health threat that can lead to numerous physical ailments such as type 2 diabetes. In fact, one-fourth of obese kids ages 5 to 10 already have at least two components of what is called metabolic syndrome, a cluster of health problems (including insulin resistance, high blood pressure and high cholesterol) that increases the risk of coronary heart disease and diabetes. Overweight kids also are more likely to be ostracized and bullied—or to bully others.

The grim reality is that obesity exerts a life-shortening effect, which threatens to reverse the steady rise in life expectancy observed in the modern era, contends a recent study published in The New England Journal of Medicine. Today’s children are on track to be the first generation in U.S. history to live less healthy, and even shorter, lives than their parents.

How did we get this way? Increasingly, experts point to our “obesogenic” environment, which encourages people to eat too much and move too little.

“We live in a world where the energy demands of daily living are at a historic low and the availability of high-calorie, easily obtainable, inexpensive food is at a historic high,” notes Harold Kohl, an epidemiologist with the Centers for Disease Control and Prevention in Atlanta. “We’ve created the ‘perfect storm’ for obesity—particularly for children.”

Numerous societal changes have dramatically reduced the amount of energy children burn, while expanding the number of calories they consume. Budget-crunched schools have cut back or eliminated physical education classes—and sometimes even recess. Working parents concerned about safety would rather their kids play video games or watch TV indoors than run around outside. Computers have revolutionized the classroom, entertainment, shopping and communication. Fast food, in “super size” portions, is everywhere—even in some schools—as are vending machines stocked with sodas and chips.

“Our willpower hasn’t changed” in just 30 short years, notes Yale University obesity expert Kelly Brownell. “The gene pool hasn’t changed.” What’s changed, he contends, “is our increasingly toxic food and physical activity environment. Society has long placed responsibility for obesity squarely on the sufferer, when we need to consider our environment as the real cause.”

Just as we dramatically altered the tobacco environment, Brownell says we must change our culture’s obesity-promoting environment. “Twenty years ago, if you said we should ban smoking in public places, people would have said you were crazy,” he notes. “People need to learn how to resist pressures to overeat and under-exercise and demand change.” Who’s at risk?

Since we’re all surrounded by pressures to sit still and overeat, no one is immune from the dangers of gaining an unhealthy amount of weight. “When you have a problem that affects one-third of the population, everyone is at risk,” says William Cochran, MD, a pediatric obesity specialist at the Geisinger Clinic in Danville, Pa., and a member of the American Academy of Pediatrics’ task force on obesity prevention. “At especially high risk are children who have one or two obese parents as well as African Americans, Hispanics and Native Americans.”

Overweight adolescents also are at high risk because their problems with weight likely will worsen with time. Physical activity tends to decline dramatically during teenage years—especially among females—and weight gain is common, Cochran says. Younger, obese teens, especially girls, battle depression more than their slimmer counterparts, and that trend continues into adulthood. “Obese adolescents have an 80 percent chance of becoming obese adults,” Cochran notes. “And obese adults tend to have obese children. So it’s important to intervene at this time to help prevent obesity in the next generation.”

The first step in preventing obesity is identifying the problem, which is done by calculating a child’s Body Mass Index, or BMI. In adults, the BMI is a single number—calculated as a ratio of height and weight—and has been used for more than a decade to define overweight and obesity. Until recently, however, BMI was not used for children because the calculations are more complicated than they are for adults. Since kids are constantly growing, you must compare their height-weight ratio to the norm for children of the same age. In 2000 the CDC released a BMI for kids that, Cochran notes, “is not a specific number; it’s a percentile.” Healthy weight falls between the 5th and 85th percentile for age and sex. Anything over the 95th percentile is considered “obese.”

Pediatricians should calculate each child’s BMI at least once a year, Cochran says. But the sad fact is, he says, they don’t always. In fact, “it’s probably happening only about 10 to 20 percent of the time.” Although pediatricians are typically excellent in preventive health measures—such as newborn screenings, immunizations and promotion of car safety seats—many have dropped the ball on prevention of childhood obesity. “Calculating BMI takes extra time, which typically physicians are not reimbursed for,” he notes. “And it can be a tense issue to bring up with parents, one that can create negative feelings and a sense of hopelessness. People often aren’t really sure exactly what to do about it.”

Cochran advises parents to ask to have their child’s BMI measured at every doctor visit, even if the appointment is for an ankle sprain or a cold. “It’s important to look for trends, like moving from the 50th percentile to the 75th percentile,” he says. “If you see this kind of significant increase, you can start taking action to keep things from getting out of control.” Some states are taking the matter into their own hands. For example, Pennsylvania recently passed a law requiring BMI to be measured every year in public schools.

Prevention is the best cure, Cochran says, adding that small steps can make a big difference in a child’s weight. “One of the key things to watch out for is sugary beverages,” he says, “since 20 percent of kids who are overweight get that way because they drink too many calories.” Consuming just 150 calories more a day than you burn adds up to a weight gain of 15 pounds in a year, he notes. Since the average adolescent male drinks three cans of soda a day, he says, “cutting back on even one 150-calorie soda can make a significant difference in a youngster’s weight.”

Fat-proof the home

A growing number of experts are calling for environmental solutions to America’s epidemic of overweight and obese kids. “If we want healthy weight kids, we need to create a healthy food and physical activity environment,” says Penny Gordon-Larsen, an assistant professor of nutrition at the University of North Carolina in Chapel Hill.

That’s why the Gordon-Larsen home has none of America’s typical obesity-promoting features, such as soda, juice drinks, sugared cereals, video games, computer toys or TVs at the dinner table or in the kids’ bedrooms. When her children—Bella, 5, and Fred, 3—are thirsty, they have two choices: water or skim milk, served in fun cups with curly straws. “I don’t give my kids juice ever at home,” says Gordon-Larsen, who notes that the recommended allowance of juice for kids ages 1 to 6 is just 4 to 6 ounces daily—the equivalent of half a juice box. “Evidence is building that our bodies aren’t set up to regulate the calories from liquid, and the sugar from over consuming juice contributes to obesity,” she says.

Nutritionally, “it’s always better to eat the whole fruit,” she says, which is why she keeps fresh fruit readily available in colorful bowls and places sandwich baggies of cut-up veggies at a kid’s eye-level in the refrigerator. If the children want a snack before dinner, she offers them broccoli florets or carrot sticks with tiny dipping cups of soy sauce. On the rare occasions she brings cookies into her house, she picks just one kind so they won’t be tempted by too many choices. Dessert is a single square of dark chocolate. The children’s TV watching is limited to one hour of commercial-free DVDs on the weekend, since numerous studies link excessive TV to obesity. The children play outdoors every day—“There’s no bad weather, just bad clothes,” Gordon-Larsen says. And the whole family enjoys active playtime together—walking, swimming or hiking—almost every day. Sounds a bit too easy, doesn’t it? Gordon-Larsen admits that she can’t monitor her kids’ choices all the time. Although “controlling the home environment can be fairly easy,” she acknowledges that it’s harder once kids start going to school, day care and friends’ homes. “You can send your kids to school with a healthy lunch, but they may want to share their friend’s chips and salsa,” says Susan Okie, MD, author of Fed Up! Winning the War Against Childhood Obesity (Joseph Henry Press, 2005). One of the most common problems Okie observed in talking with families struggling with weight issues is “not to make it into a control battle between parent and child,” she says.

As an example, Okie points to 10-year-old Meagan, a Los Angeles girl who was beginning to be teased at school about her weight. “Part of her wanted to go with the healthy eating plan and not be teased,” she says. “But part of her wanted to eat ice cream and cookies and not have anyone tell her what to do.” While parents need to be concerned, Okie cautions that “negativity and nagging don’t work.” Okie advises parents to get support from a health professional, such as a nutritionist, nurse practitioner, physician or other provider skilled in behavior change. Praising healthy behaviors—not just rewarding weight loss—is important in achieving lasting results. “It’s not about dropping 10 pounds in a month,” she says. “The goal is to create a life-long change of habits.”

Fat-proof the community

The Gordon-Larsens are fortunate to live in a “walkable” community called Southern Village, which is designed to allow residents to walk and bike to playgrounds, schools, recreation facilities, restaurants and the grocery store. Model communities like this one are being created across the nation as more and more research confirms that lifestyle diseases such as obesity (and related conditions including diabetes, high blood pressure and high cholesterol) require lifestyle solutions. This involves changing our “obesogenic” environment to make it easier for people to move more and eat better—at home, in schools and in the community.

“Past attempts to solve the obesity problem have failed, at least in part, because we’ve mostly focused on the individual,” says Allen Dearry of the National Institute of Environmental Health Sciences, which sponsored a conference this spring on Environmental Solutions to Obesity in America’s Youth. “It’s very difficult for an individual to adopt healthy habits if his or her surroundings make it hard to be active and eat well. For individual behavior change to be successful, we have to create an appropriate environment.”

Researchers at Tufts University in Boston are doing just that as part of a three-year project called Shape Up Somerville: Eat Smart, Play Hard,. Through a variety of strategies, such as making it safer to walk or bike to school and offering healthier options for school lunches, “we’re assessing the impact of healthy environmental changes on the weight of students in grades one through three,” says the study’s principal investigator, Christina Economos, of the Friedman School of Nutrition Science and Policy at Tufts. “This is an important age group to intervene in because if you can get overweight kids to be active and eat right, you can help them grow into their weight.” While research results won’t be available until later this year, preliminary data suggest that the intervention has made significant improvements in the children’s BMI, she says.

Parents need to get involved in their schools and communities to advocate for more opportunities for their kids to be active and have healthier food choices, says Economos, who advises getting rid of fund-raisers that involve candy and selling wrapping paper or fruit instead. “Our children are being overwhelmed with treats today,” she says. “There’s no reason why parents should show up with donuts and soda when it’s their turn to bring a snack.” Instead, she recommends providing parents with a list of acceptable options, such as orange slices and water. Parents can also lobby for quality daily physical education classes, she says, and afterschool programs that promote active play—not sitting around in front of computer and TV screens.

One of the best things parents can do to promote healthy weight for their children is to “be a good role model,” says Economos, who has two young children. “As a parent I try to follow the guidelines for healthy eating and physical activity. We hike, swim and bike together as a family and try to get outdoors as much as possible. Sometimes we just put on the music and dance.” Finding time for fitness is “a matter of priorities,” she says. “We don’t watch TV. The average American watches four hours of TV a day. So if you cut back on this, it’s pretty simple to find time to be active.”

Make it a family affair

Everyone in the family—including siblings and grandparents—should be encouraged to eat right and exercise to successfully combat childhood obesity. According to William Strong, MD, emeritus professor of pediatrics and cardiology at the Medical College of Georgia in Augusta, “If you tell a child to be active and eat better and the family isn’t doing it too, it’s a set-up for failure. Instead of sitting on the bench at the playground, get up and play with your kids.” Roll a ball back and forth, take walks and, if your child is old enough and interested, take an active class together, such as martial arts or yoga. To make time for physical activity, he says, “parents should reduce screen time (TV and video games) to less than two hours per day.”

Sadly, some children are active only about 10 minutes a day, notes Strong, who, along with Robert Malina, is author of a new recommendation published in the June issue of the Journal of Pediatrics, calling for school-aged children to participate in 60 minutes or more of moderate to vigorous physical activity daily. “If you don’t have 60 minutes all at once,” he notes, “it can be broken up into shorter bouts.” The benefits of daily physical activity go far beyond weight control. Research links regular exercise with a host of health benefits including a stronger heart, lungs, muscles and bones, as well as better concentration, memory, classroom behavior and academic performance.

One of the most important ways to make sure kids will be active is to make movement fun. “Activity has to be enjoyable, so people will continue to do it,” he says. “Find something active your children like to do and encourage them to do it. If they have a good time, they’ll want to do it again and again. And that’s how you create good health habits that last a lifetime.”

Tater Tots!

Sitting in front of a screen sipping sugary drinks and eating fatty foods is a daily fact of life for most American kids. For example:

• Children 6 and under spend an average of two hours a day using screen media (TV, computers, video games), and the average child watches three hours of TV a day. Higher levels of TV viewing are associated with higher levels of obesity. 
• Thirty-six percent of kids under 6 years old have a TV in their bedroom, and 26 percent of children under 2 have a TV in their bedroom. 
• Walking or biking can be deadly, since many towns have no pedestrian or bike lanes. Pedestrian fatality is the third leading cause of injury-related death among children 5 to 14. This may explain why 75 percent of trips a mile or less are made by car, and only about 14 percent of trips to school are made by walking, down from 50 percent in 1969. 
• Kids are bombarded with food commercials—the average child sees 10,000 per year, with 95 percent of them being for candy, fast food, soft drinks and sugared cereals. 
• Daily P.E. classes are only offered by 8 percent of elementary schools, 6.4 percent of middle schools and 5.8 percent of high schools.

What you can do:

• Practice what you preach. Don’t expect more from your kids than you’re willing to do yourself. Make these changes for the whole famly.
• Eat family meals, with no television. 
• Offer nutritious snacks, such as vegetables and fruits, low-fat dairy foods and whole grains. 
• Teach children about proper portion size, and encourage moderation rather than over consumption: Don’t insist on “cleaning the plate” and avoid using sweet treats for rewards. 
• Use low-fat dairy products. After age 2, kids should drink low-fat milk. 
• Eliminate carbonated beverages and high fructose corn syrup. Use only 100% fruit juice and limit that to 4 ounces daily for toddlers and 6 to 8 ounces for older children. 
• Prioritize and promote physical activity, and be sure that your kids get at least 60 minutes of moderate to vigorous activity every day. 
• Breastfeed infants exclusively for at least the first four to six months of life. Research shows that breastfeeding reduces the risk of obesity. 
• Limit recreational (non-school) “screen time” (computers, TV, video games) to no more than one hour a day.
• Do not allow TV in a child’s bedroom. 
• Advocate in the schools and community for healthy food choices and adequate opportunity for regular physical activity. 
• Have your doctor calculate your child’s BMI at least once a year. Learn more at www.cdc.gov/nccdphp/dnpa/bmi/bmi-for-ages.htm.