This is the second article in a two-part series. The first part addressed the scope and implications of childhood obesity; this second part focuses on solutions and their implementation.
When Dr. Robert Murray states that from a public health perspective, no issue is more important than the future implications of obesity among children, we need to listen. And then act.
Dr. Murray is the chair of the American Academy of Pediatrics Council on School Health and advisor to the national Action for Healthy Kids initiative. He is also the director of the Center for Healthy Weight and Nutrition at Nationwide Children's Hospital and professor of clinical pediatrics at the Ohio State University College of Medicine.
The magnitude and scope of obesity among children is receiving increased attention, as evidenced by the November 6 Dr. Phil show titled "Top Three Ways You Are Making Your Child Obese." But what's causing our children to get fat, what is the solution and how can we implement the needed changes? Dr. Murray responds to these questions below.
1. What are the causes of increasing childhood obesity?
Researchers have focused their attention on the mid-1970s, when the rise in excess body weight among Americans, adults and children alike, began. Although the media frequently cites fast food, video games or high fructose corn syrup as "the cause," the fact is that many factors played a role in that decade. Soft drinks became the national drink, replacing water and milk. Processed snack foods proliferated.
In addition, cable television, home movies and the first computer games became established. The information age developed, along with computers at work and later at home. Suburban layouts fostered more driving and drive-through businesses. Commutes became longer. The list of causative factors goes on and on, making obesity a complex public health problem. No one problem caused it, and no single solution will make it go away.
2. Whatever the causes, are parents addressing the issue?
Parents' early recognition and intervention is critical because studies have shown that if a child becomes overweight early in life and maintains that weight beyond age 10 years, the likelihood of being an overweight adult is 80 percent. But if a child is not overweight by age 10 years, the likelihood of becoming overweight by middle age is only 10 percent.
To the child's detriment, however, parents frequently don't recognize overweight in their children, and physicians don't screen regularly enough to alert them.
An example from my practice is a mother who came to the Center for Healthy Weight and Nutrition with her 13-year-old son. From the time her son was six-years-old, her physician had warned her that he was carrying too much weight. When she came to see me, the young man was diabetic, had high blood pressure and had elevated cholesterol, all putting him at great risk for cardiovascular disease. The tearful mother felt guilty, worried and helpless to turn around her child's weight, which now approached 300 pounds. She herself had struggled with obesity her whole life and suffered from similar health problems. Now she sees her son traveling down the same path.
Sadly enough, this story isn't uncommon. Among obese school-age children, consistently one-half to two-thirds of their parents fail to recognize the problem until the children are teens, if at all. The results are even worse for preschool-age children. Studies showed that only 17 percent of parents of obese three- to five-year-olds recognized their young children as overweight. And physicians have not yet made BMI measurement a regular part of their office visits. Physicians nearly always measure height and weight. But fewer than 20 percent, and in many studies closer to 5 percent, regularly plot BMI percentile. This may be the best justification for screening for BMI in preschool, kindergarten and early elementary school.
3. What are some remedies? What advice can you give to parents?
Recently, 15 national health-care organizations convened to write guidelines for the care of obesity in children and adults. For children, the guidelines were published as a supplement to the journal Pediatrics in December 2007. Along with clear directives to clinicians about the steps needed to approach children with overweight, the expert committee identified 10 core recommendations that research had shown would help prevent obesity or treat children with excess weight. They included
• Support exclusive breast-feeding for the first 6 months of life.
• Limit sweetened drinks.
• Limit television time to 2 hours per day or less, and do not put televisions in children's
• Do 60 minutes per day of moderate to vigorous activity.
• Consume five to nine servings per day of fruits and vegetables.
• Consume a nutrient-rich diet, high in calcium and fiber.
• Eat dinner as a family five to six times per week.
• Limit eating away from home, especially fast food.
• Limit portion sizes.
• Consume a nutritious breakfast every day.
Breakfast is a critical meal. One of every three teen girls never eats breakfast, and most teens skip it often. Skipping meals sounds like a good idea for overweight, but studies are very clear: skipping meals leads to greater rates of obesity. After an overnight period of fasting, three actions have been associated consistently with a lower risk of obesity: eating breakfast every day, eating cereal, especially whole grain cereals, and drinking milk.
As a society, our best bet is to emphasize prevention by carefully establishing good dietary and activity habits in our newborn children and maintaining good habits through school age. The critical messages from the expert committee, the U.S. Dietary Guidelines and numerous medical studies have been included in a resource called An Ounce of Prevention, available for free to clinicians. It can be found at www.NationwideChildrens.org/HealthyWeight. In it are parenting tips encouraging healthy eating and offering proper portion sizes, snacks and calcium products, among other important tips.
4. At the national level, what policies need to be changed? Is there a model program that communities can follow?
If primary care clinicians can help establish a solid home environment around the child, with well-educated parents and good habits established, then the next targets are school and community policies to wrap around the child and family.
School policy has come a long way in the past 10 years. Many schools have abandoned sweetened beverages, cleaned up snack foods in the a la carte lines and improved the quality of school lunches. Three sets of studies of the nutritional quality of school lunches compared with lunches of children eating outside the National School Lunch Program have shown better nutritional quality in the school lunches.
Unfortunately, the available funding for school lunches is extremely limited, making it a significant challenge for school nutrition services to offer more expensive options such as fresh fruits, vegetables and whole grains.
School wellness committees, mandated in 2006, have helped write school policies that have greatly improved not only vended foods and other options but also foods served at classroom parties, foods sold by booster clubs and during sporting events and other, more hidden, ways that low-nutrient, high-calorie foods surround children in school.
Part of the solution will be industry. Although the food and beverage industries have been vilified by many, they have been very responsive to new standards. For schools, however, there are no national standards. Instead, individual states have begun to pass their own standards, making it nearly impossible for industry to respond with a uniform set of products.
In response to this, the Senate has directed the USDA to begin drafting such standards. Over the past three decades, nutrition standards have all been written the same way. They have specified what Americans should not eat, such as fat, saturated fat, trans fat, sugar, sodium and so forth. Most set limits and any foods that fail to stay within those limits are eliminated.
The U.S. Dietary Guidelines set out a new direction for standards, calling for a greater emphasis on nutrient-dense or nutrient-rich foods. This means that every calorie should offer a nutritional benefit. Compare a soft drink with 10 teaspoons of sugar, water and caffeine versus a glass of chocolate milk with two teaspoons of sugar plus calcium, vitamin D and seven other important nutrients. The former is empty, the latter is nutrient rich.
The Center for Healthy Weight and Nutrition has established collaborations with many community organizations to help shape the three environments in which kids grow: home, school and community.
Along with the Ounce of Prevention project, we have been funded by a local foundation and by United Way to establish educational programs for parents of children in 30 high-risk inner city neighborhoods. We have begun to tailor resources to help the primary care physician conduct obesity counseling in a more efficient manner. For schools, software was created to help them determine the nutritional quality of snack foods offered, which can be reviewed at www.Snackwise.org.
We have also begun work with the school nurses in Columbus, Ohio, to help better understand how to make the information from BMI, insulin resistance, and blood pressure screenings among school children more relevant for parents, so they work with their doctors to address overweight rather than ignore it. Our example can be replicated in other communities.
5. We have many other pressing issues, from global warming and healthcare reform to H1N1 virus and unemployment. Where does the issue of childhood obesity rank among these urgent concerns?
After decades of work, cardiovascular disease morbidity and mortality are falling. The rising epidemic of excess weight with the associated disease risks probably will undo all of that progress over the next couple of decades. As I've told pediatricians, it won't do children any good to get all their immunizations if we allow them to develop cardiovascular disease and diabetes in young adulthood. And childhood obesity is preventable, not inevitable.
The hope is that health-care reform, in whatever form it takes, shifts our emphasis from disease treatment to disease prevention, where it belongs. This will require reimbursement rates for primary care physicians to do this job well. The roots of obesity are in childhood with its manifestation of disease in adulthood. No parent dreams of their children growing up to be sick young adults tied to the need for constant medical care. And from society's perspective, the medical costs to care for this generation of children will be enormous. We can't afford to do nothing.
It's not about the one perfect diet from the New York Times best-seller list or that every child needs to be in sports every day. We need to establish positive habits for a good quality diet and daily activity that is part of everyday life. To accomplish this, communities need to pull together and recreate the three critical environments in a way that makes being healthy and fit fun.
Dr. Murray's comments affirm that childhood obesity isn't a problem that we can delegate to politicians, physicians or schools. As parents, grandparents, aunts and uncles, we need to address the issue in our own circle of influence. Setting a personal example is the most important message we can send to those around us. Our second action is to join others in creating children's fitness protection programs in our communities. For more ideas on how you can help, you can contact Dr. Murray here.