A Heavy Burden
With childhood obesity on the rise, learn how you and your community can help children adopt better habits

By Kristen Laine

Here's a quick quiz: What health problem currently affects nearly one-third of U.S. adults, has quadrupled among children and tripled among adolescents in one generation, is associated with an estimated 300,000 deaths each year, and is completely preventable? For bonus points, what health problem, according to a statement from the U.S. Surgeon General in 2001, threatens to reverse many of the health gains achieved in the United States in recent decades?

The answer to all these questions is the same: obesity. And the issue has made headline news. What you may not realize is how large the problem is—and how quickly it has ballooned. In recent years, obesity has increased in every state and among both sexes, regardless of age, race, or educational level, according to researchers at the Centers for Disease Control and Prevention (CDC) (Journal of the American Medical Association, 1999, vol. 282, no. 16). "Rarely do chronic conditions such as obesity spread with the speed and dispersion characteristics of a communicable disease epidemic," says William Dietz, MD, PhD, director of the CDC's Division of Nutrition and Physical Activity. The health concern has also been called "an American epidemic" by Senate majority leader Bill Frist, who was a cardiac surgeon in Tennessee before being elected to the Senate.

Particularly troubling is the epidemic's reach into America's youth. Chronic conditions such as obesity usually take years to develop and therefore affect adults more than children. When most of today's parents were children, only 4 percent of children aged 6 to 11 and 6 percent of adolescents aged 12 to 19 were considered obese. But in the past 25 years, the prevalence of obesity among children has nearly quadrupled—to 15.3 percent, according to 2000 data from the CDC. Among adolescents, the rate of obesity has nearly tripled during the same time, to 15.5 percent. More than 10 percent of preschoolers—children between the ages of 2 and 5—are considered obese. When you add the children who are merely overweight (approximately 20 percent over their recommended weight), nearly half of all American youth are at risk for the numerous long-term health complications of obesity.

The obesity epidemic in America shows no signs of slowing. If nothing changes, today's children are likely to become the first generation of Americans to have a shorter life expectancy than their parents did. The good news is that a few commonsense steps can start us on the road to reducing childhood obesity in our communities and nationwide.

The Cost Of Living Large
Obesity's cause is deceptively simple: If you eat too much and exercise too little, you gain weight. If you persist in eating too much and exercising too little, you become obese. Obesity's health ramifications are numerous and complex, and the younger a person is when he or she becomes obese, the more they add up.

An overweight child is more likely to suffer from asthma, high blood pressure, orthopedic complications, gallstones, sleep apnea, and type 2 diabetes than a child of normal weight. Obese girls tend to begin puberty early, even before the age of 10, which can lead to endocrine problems in adulthood. Obese children, especially girls, are also at increased risk for certain brain tumors. Overweight children are often teased or shunned, tend to think less highly of themselves, and are more likely than their normal-weight peers to be depressed.

Type 2 diabetes, a chronic disease for which obesity is the number-one risk factor, was virtually unknown in children as recently as ten years ago, according to the CDC's Dietz. Type 2 diabetes in children and adolescents now accounts for almost 50 percent of new cases of diabetes in some communities. Diabetes inflicts severe cumulative damage on its victims, in the form of heart disease, strokes, and nerve, kidney, and eye damage.

Measure your child's body mass index Healthy body weight in children correlates closely with height. Health professionals often use body mass index (BMI), calculated from height and weight measurements, to assess whether a child is overweight. To figure your child's BMI, go to www.keepkidshealthy.com and click on BMI Calculator. Remember, these are just guidelines; it's always best to work with your child's health care provider.

Health problems multiply when an obese child becomes an obese adult. Researchers have linked obesity to colon cancer, breast cancer, and stomach cancer. Obesity complicates everything from pregnancy and childbirth to surgery and getting a job. It hastens the ultimate health issue: Statistically, overweight adults die sooner. A 1999 study by the American Cancer Society found that severely overweight people were four times more likely to die young than people of normal weight. Unfortunately, one of the best predictors of whether someone will be obese as an adult is whether he or she was obese as an adolescent.

Obesity is also expensive. U.S. hospital costs tied to childhood obesity were $127 million in 1999. In the same year, annual health care costs stemming from obesity were estimated at $238 billion; experts expect those figures to increase.

An Epidemic With Many Causes
Why do we have widespread childhood obesity? Many reasons exist, all of them feeding off each other. The United States is, as the title of a recent New York Times best-selling book suggests, a "fast-food nation." A generation ago, most families ate food cooked at home. Today people spend about half their food budgets in restaurants, most of them fast-food. American children eat fast food three to six times a week, on average, and often eat it in supersized portions. Teenage boys drink twice as much soda as they do milk, exactly reversing figures from two decades ago.

We are also a sedentary culture. U.S. children aged 2 to 18 currently spend an average of 38 hours a week in front of TVs, video games, and computers. This is a full workweek of hours not spent outside or in other physical activity. TV time creates additional temptations. Almost a thousand commercials air every Saturday morning, and two-thirds of cartoon-show ads promote high-calorie foods.

Nationwide, schools have done little to pick up the slack created at home. Most school districts have trimmed or eliminated recesses and physical-education classes. Only one state, Illinois, requires daily physical education for students from kindergarten through 12th grade. What's more, many schools line their hallways and cafeterias with soft-drink and candy vending machines, receiving a portion of the sales. Not just the poorest districts accept this cash infusion. A CDC study in 2000 found that 49.9 percent of school districts across the country have signed contracts with soft-drink makers (see "School Snack Attack").

Downsizing
In the midst of all the bad news about obesity is the simple fact that it is preventable. Although researchers have yet to find solutions that work for all children at risk for obesity, family-based programs provide the most consistent success. For the past 15 years, Melinda Sothern, PhD, MEd, CEP, has directed one of the most successful of those programs, the Committed to Kids Pediatric Weight Management program at Louisiana State University's Health Sciences Center in New Orleans. She and her team have treated more than a thousand children and their families. Sothern's approach factors in a child's age and weight and includes family treatment, nutritional guidance, and exercise. The team has trained other medical professionals in its methods and written a book, Trim Kids (HarperResource, 2001), which lays out a 12-week program that families undertake with the help of their pediatricians.

The Trim Kids program gives a sense of how simple—and how hard—it is to help a child lose weight. The program supports children in becoming more active and in eating smaller portions of more-nutritious foods. But the program is also all-encompassing, restructuring a family's entire approach to food and exercise. (See "Tips for Weight Maintenance" for more ideas.)

Underlying the Trim Kids program is the belief that a child's weight loss starts with a parent's commitment. Children, even teenagers, need a parent's guidance and support while learning new behavior, says Sothern. They also need a parent's help with setting limits. Numerous studies have shown that weight-loss programs are more effective when at least one parent is involved.

Next are the twin pillars of exercise and nutrition. "My big push is play," says Sothern, a former swim coach. "Our kids are rarely allowed to just play, and yet being active is crucial to a child's well-being." Time that children used to spend in unstructured play now often goes to watching television, playing video games, or sitting in front of a computer. Many studies have shown that reducing the time a child spends in front of a flickering screen reduces his or her weight. "Play before homework," Sothern tells the parents in her program. "Send your children outside, if possible, for at least 30 minutes every day—an hour is even better—before they start their homework."

Of course, children exercise differently from adults, Sothern warns. Before children reach puberty, they aren't physiologically able to exercise vigorously for long periods of time. What they do have is the ability to run fast for short periods, then stop and rest. Children can burn 350 to 400 calories an hour this way, and their stop-and-go activity can last an entire day. For older children, sustained moderate-intensity activity—walking, hiking, biking—is an excellent weight-management tool.

Helping families develop a healthier relationship with the food they eat is the task of Heidi Schumacher, RD, LDN, CDE, nutritionist for the Trim Kids program. She encourages parents to set specific guidelines for family meals. Family members should be together, sitting at a table and eating slowly without distractions.

Snacks that children eat during the day, after school, and in the evenings are another problem area. Schumacher encourages parents to create "a safe food environment"—for example, getting rid of unhealthy snack foods and replacing them with fruits and vegetables. She also recommends something called "cue elimination": "If Twinkies or chips aren't in the house, you have an easy way to say no, and the children can't be tempted to eat them. That food battle simply goes away." Eventually, eliminating the cue to eat unhealthy foods works to eliminate the desire for them.

Schumacher also works with families to understand hunger. She doesn't insist that children in the program start out eating breakfast. Instead, she asks them to notice if they're hungry when they wake up in the morning. If children aren't hungry, she says, they're probably eating too much at night. "Once they cut back on nighttime eating, getting them to eat breakfast is a breeze," she says.

A nutritious diet includes not only what a child eats, but also what a child drinks. "We should be a lot more diligent about [monitoring] what our kids are drinking," Schumacher says. "It is fairly common for kids we work with to have been drinking more than a thousand calories per day in sugar-laden beverages. A 16-ounce soda contains more than ten spoonfuls of sugar. You'd never sit there and feed a child ten spoonfuls of sugar. But that's what you're doing when you give a child a can of soda." Replacing sodas with glasses of water or even fruit juices often contributes to significant weight loss.

Other organizations have joined Trim Kids to encourage families and schoolchildren to experience food in different, healthier ways. Oldways Preservation and Exchange Trust, a food-issues think tank based in Boston, has developed a unique curriculum for middle-school students that introduces them to food cultivation, food history, and especially food preparation around the world. In one of the lessons, students make their own whole-wheat pita bread. "Preparing food is a sensory experience," says Deborah Good, communications director of Oldways. "You put the pita bread in their hands, they pat it, turn it over, and next thing you know ... they're asking their parents to buy the ingredients," she says.

Oldways has also developed food pyramids based on healthy diets from other cultures. These shed stark light on the typical American diet. Oldways promotes the Mediterranean diet, which includes several servings a day of dark, leafy green vegetables. By contrast, Good says, the typical U.S. diet contains less than half a serving a week of nutrient-rich green vegetables. "Simply taping one of these food pyramids to the refrigerator door," says Good, "can spark conversation and, eventually, change."

Creating A Mind Shift
Turning the tide of the childhood obesity epidemic will require broad-based changes in our communities and across the country. Researcher Melinda Sothern believes that such change is both necessary and possible. "We need a social shift in consciousness like we had with smoking," she says. "We think it's normal behavior to eat fast food four or five times a week. We need to make it unacceptable to eat this food, to drink soft drinks. We want kids to say, 'Yuck, you drink soft drinks? Don't you know how bad that is for you?'"

Sothern suggests that parents start with the schools. "I tell parents, march up to your school administrators," she says. "Ask for three simple things: daily PE, daily recess, and an appropriate lunch. If your school administrators won't do anything, go to your PTA. If they won't do anything, go to your school board, start a parents' group. Make it happen."

On a national level, Senate majority leader Frist is trying to pass the Improved Nutrition and Physical Activity Act (IMPACT), legislation he first introduced in 2001, aimed at reducing obesity among children and adolescents. The Physical Education for Progress (PEP) program is in its third year of promoting physical education in schools and communities through grants for teacher training and equipment. The program started in 2001 with $5 million; in 2003, in spite of a lack of support from President Bush, PEP received $60 million from Congress.

Congress banned cigarette advertising in the 1970s. Perhaps advertising to children, with its preponderance of junk-food ads, will be next. In 1995, the American Academy of Pediatrics declared that "advertising directed toward children is inherently deceptive and exploits children under 8 years of age" but stopped short of supporting a ban. Sweden went further. In 1991, the country banned all TV advertising directed at children under age 12. Governments have also imposed restrictions on advertising during children's programming in Greece, Norway, Denmark, Austria, and the Netherlands.

The children we are raising now will have to live with the results of our national slide into obesity. On one level, the answers are simple, and we've known them for years. But changing how we eat and exercise is hard work, as anyone who has tried can attest. Changing an entire nation's behavior will require an enormous exercise of political and civic will. Likely we will need to ask, and answer, many more questions before we can stop the obesity epidemic.

Freelance writer Kristen Laine is a frequent contributor to Delicious Living. Her last article, on midlife pregnancy, appeared in December 2002.