Changing the Shape of the Future
At a time when Americans revere the super-sized combo meal and children spend hours glued to televisions or computers instead of playing outdoors, researchers and health officials are seeking strategies to curb an epidemic of childhood obesity.
An estimated 10% to 15% of American kids are seriously overweight, a near doubling over the last two decades, federal figures show. As many as 25% are at risk for obesity and many already show biochemical changes such as elevated cholesterol and blood pressure that are precursors to obesity-linked illnesses.
Increasing numbers are even being diagnosed with maladies that weren’t thought to strike until the grown-up years, such as so-called adult-onset, or type 2, diabetes. As these children age, heart disease and diabetic complications like kidney failure loom.
“As this wave of obesity moves into adulthood, we’re going to be seeing greater health costs associated with [it],” said Dr. William H. Dietz, director of the Division of Nutrition and Physical Activity at the federal Centers for Disease Control and Prevention in Atlanta. “It’s crucial we develop effective prevention programs as well as effective treatment for the 10% to 15% that are already overweight.”
Most doctors define obesity in children as being at or above the 95th percentile for weight based on height and gender. They become concerned at the 85th percentile, especially if children already show warning signs of illness.
Although genetics plays a role in susceptibility to obesity, it’s environment that determines whether many children will put on extra pounds. So researchers are trying to understand not only kids’ relationship to food, but how the home, the school cafeteria, class curriculum and popular culture drive eating behavior--and what could be used to combat obesity.
“If there were a magic bullet, we would have done it a long time ago,” said Eileen Kennedy, a deputy undersecretary at the U.S. Department of Agriculture, who is responsible for the new Behavioral Nutrition Research Initiative.
As part of that initiative, the department has made obesity research a priority and has conducted several conferences to identify possible solutions. At a recent USDA-sponsored meeting in New Orleans, nutritionists, pediatricians, psychologists and government health officials began identifying studies that could help shape public policy.
Some researchers have pinpointed risk periods in a child’s life that could become target times for stepping in with prevention or treatment. One is the so-called period of adiposity rebound--the point when a young child’s body fat increases after several years of decline, usually around age 5 or 6; a 1998 study found that if they reach that point before their fifth birthday, the child is twice as likely to be an obese adult. The other key time is adolescence, when hormones kick in.
This year, the CDC has almost $5 million to help develop obesity interventions for children and adults. About half will go to states for local projects; the remainder will underwrite research into links between behavior and obesity to help health officials figure out where they can make a difference.
Although obesity crosses ethnic, racial and economic lines, it disproportionately strikes Native Americans, African Americans and Hispanic Americans, said Dr. Francine R. Kaufman, head of endocrinology at Childrens Hospital Los Angeles. “Our minority children particularly are living in poverty and are much more prone. The real behavioral issue is they’re not going off and getting fresh jicama. They’re going to McDonald’s.”
Many of the innovations explored in recent years have targeted lower-income and minority kids.
Among researchers reaching out to those populations is Dr. Thomas N. Robinson, a Stanford University pediatrics professor, who has just begun developing a federally funded program for 8- to 10-year-old African American girls. It will probably incorporate traditional African dancing and education about their African heritage to make exercise more enticing and relevant to their lives. Similar programs might use other types of dance because it’s an appealing way to get youngsters burning calories.
Reasons for Weight Gain
Putting on excess pounds is a matter of taking in more calories than the body uses and converting them to fat. Successful bulge-battling involves increasing activity and decreasing caloric intake.
That may sound simple, but it’s not.
Humans have become an increasingly sedentary species. They were evolutionarily built to store fat to survive during famine, said Michael Goran, a visiting professor at USC’s Institute for Prevention Research. “Right now we have an abundance of low-quality, high-calorie food and an environment and lifestyle that requires less physical activity. We’re storing energy, but there ain’t no famine.”
So much of contemporary culture conspires against restrained eating and exercise. Packaged convenience food and inexpensive fast food that parents pick up on the dash home save time but pack calories from fat and sugar. The increasing popularity of television (Nielsen data suggest kids are watching about 21 hours a week), video games and computers has brought a generation indoors--often with a bowl of salty, high-calorie snacks nearby. Further, new suburbs are designed with automobiles--not sidewalks and pedestrians--in mind. Street crime and drive-by shootings in some neighborhoods make outdoor activities, including pickup games and after-school bicycle rides, potentially life-threatening propositions.
And in schools, emphasis on core skills has come at the expense of physical education classes. According to the CDC, the percentage of high school students who attended daily gym class dropped from 42% in 1991 to 27% in 1997. Of youngsters enrolled in gym classes in 1997, 27% reported they didn’t exercise for 20 or more minutes during most sessions. So even a physical education requirement (California mandates 200 minutes every 10 days in elementary school and twice that for junior high and high schools) doesn’t guarantee kids’ hearts are pumping any harder.
“Middle- and upper-income parents buy their way out of the problem by putting their kids in physical activities,” like league sports, said Kennedy in an interview from home before driving one of her sons to a suburban Virginia basketball game.
Although schools do teach rudiments about the food pyramid, they haven’t gotten through to children--or their parents--about following a balanced diet or negotiating through the fast-food restaurants that not only dot their towns, but often have concessions in school cafeterias.
“We’ve missed the boat on bringing in lifelong enjoyment of healthy physical activity, and we’ve missed the boat many times in healthy eating patterns because that has not been a part of the reading, writing and arithmetic,” said Gail Frank, a nutrition professor at Cal State Long Beach who counsels overweight children and their families.
And a generation of heavier parents--best estimates say a third of adults are obese and as many as half are moderately overweight--are raising heavier kids.
An overweight preschooler with normal-weight parents has a 25% chance of being an overweight adult, said Dr. Robert Whitaker, an associate pediatrics professor at the University of Cincinnati College of Medicine. If that same preschooler has an overweight parent, there’s a 60% chance of growing into a fat adult.
On the other hand, “normal-weight parents who have heavy kids under the age of 3 don’t really need to worry,” Whitaker said. “About 90% of those kids are not going to be obese as an adult.”
In other words, most pudgy little ones grow out of their baby fat, so parents needn’t obsess.
However, if that child reaches preteen years and remains overweight, “the chance of being overweight is high regardless of whether the parents are overweight,” Whitaker said.
Although children are miniature adults in some ways and unconsciously copy what Mom or Dad does at the dinner table, the ways adults choose to slim down aren’t necessarily optimal for children.
According to health experts, the best approach to controlling eating among the young is not to drastically lower their calories, but to stabilize body weight through healthy eating and increased activity that essentially lets them grow into their weight.
But sometimes kids have little guidance to direct their food decisions. For example, with most parents working, preteens are preparing or buying their own breakfasts and lunches, while those as young as 9 often are responsible for their after-school snacks.
“We’ve turned over this responsibility to kids, yet we haven’t given them the knowledge or information they need,” said Frank, a spokeswoman for the American Dietetic Assn. For example, many youngsters don’t know that the fat content of food is driving the 600 to 1,200 excess calories they may take in daily. Or that skipping breakfast leads to ravenous afternoon eating. Or that a reasonable portion of many foods is just a half-cup.
“We would fail a math course if we had to accurately identify portions,” Frank said.
The USDA’s Kennedy, a nutritional epidemiologist, said kids aren’t motivated by health consequences of how they eat. Instead, they think about whether it will improve their athletic performance or affect their appearance. “It’s here-and-now, short-term satisfaction.”
Making a Difference
National outreach programs combining public and private funds are now trying to make learning about food fun, in hopes that more children will master basic dietary guidelines. But some of the most effective programs work with small groups of kids, combining exercise with nutrition information.
The goal is to help overweight kids and their families cope with stress, embarrassment and health threats.
At Childrens Hospital Los Angeles, half a dozen preteen and teenage boys referred by their doctors or school health officials gather weekly for Kids ‘N’ Fitness, a program organizers hope to expand into the schools.
Physical therapists guide the boys through volleyball, jumping rope or hip-hop dancing for 30 minutes, while a nutritionist takes over the next half-hour on food issues, including nutrition labels, dining out, snacks and portion sizes. On a recent day, when asked how to make restaurant selections more healthful, the boys suggested substituting chicken for beef in a burrito; having salad dressing on the side; taking home half a sandwich for the next day’s lunch.
The messages were getting through.
Before joining the program, “I used to eat like crazy,” said 13-year-old Juan Letona of Hollywood. Now the smiling middle-school student reads food labels for fat content--”I multiply calories from fat by three and if it’s higher than the calories overall, I don’t eat it.”
Although girls are known to be sensitive about their appearance, boys are sensitive about their weight too, especially when weight gain interferes with athletic performance.
Juan says he still “can’t do a pull-up; sometimes I get out of breath.” Nevertheless, he relishes his afternoon basketball games at a neighborhood youth center.
Ryan Hoover, a 14-year-old who at 5-foot-11 towers over his pals, suffers from an unusual combination of both juvenile and adult-onset diabetes, diagnosed when he was 10. He relies on an insulin pump that delivers 200 units of the sugar-metabolizing hormone each day.
Because his unstable blood sugar periodically lands him in the hospital, he’s focused on improving his health. To encourage more exercise, Ryan’s parents bought him an 18-foot trampoline. In cooler months, Ryan takes his three dogs for walks to a park near his La Crescenta home.
A Change of Dietary Habits
After nine weeks of substituting broiled chicken for fried and apples for fatty snacks, he’s down to 196 pounds. Unlike many overweight kids who are teased, his height shields him: “I can’t say people make fun of me because they don’t; I could beat them up.”
Although teenage years are tough on most kids, those who are overweight can feel particularly burdened. The hospital program lets them relate to peers in similar straits. Said Ryan: “You know there’s other people too.”
Although small-scale efforts to change family habits are crucial to fighting obesity, federal officials have begun some national programs.
The CDC is aiming to revive the days when youngsters ambled to school with its KidsWalk-to-School project. Currently, only a third of children living within a mile of school walk there and the CDC hopes to change that. So far, communities in North Dakota, Massachusetts and Alabama are designing programs to provide adult supervision along routes to and from elementary or other schools within a mile of home.
But getting kids up and moving is only part of what’s needed to change the habits that foster obesity.
“Single efforts here and there aren’t going to make a big difference,” said the CDC’s Dietz. “We need to address physical activity and diet in a variety of settings; we need to improve counseling by pediatricians and improve school-based programs, including the restoration of physical education, and we need to think about community approaches.”
Researchers used to focus mostly on teenagers and preteens but now are aiming younger, trying to get through to children when tastes and eating habits are being formed.
“We believe to make any significant change, you want to develop programs that span the entire age range. You want children . . . to be hit multiple times,” said Stanford’s Robinson, who has several pilot programs, funded by the National Institutes of Health, running within predominantly low- and middle-income regions of the Bay Area. The school-based programs combine fitness, curriculum and changes in the school cafeteria.
“Our goal is to give them multiple opportunities to develop these behaviors and to hopefully maintain them for the long run.”
(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)
Overweight Children
The overall percentage of children classified as overweight has risen sharply during the past 25 years. And there are significant differences in the rate of overweight children based on ethnicity.
*--*
Sex, age, race 1976-80 1988-94 6-11 years (Percent of population) Boys and girls 7.6 13.6 Boys 8.1 14.7 White 8.1 14.6 Black 8.6 15.1 White, non-Hispanic 7.4 13.1 Black, non-Hispanic 8.6 14.7 Mexican American 14.5 18.8 Girls 7.1 12.6 White 6.5 11.7 Black 11.5 17.4 White, non-Hispanic 6.2 11.9 Black, non-Hispanic 11.6 17.7 Mexican-American 10.7 15.8
*--*
*
*--*
Sex, age, race 1976-80 1988-94 12-17 years (Percent of population) Boys and girls 5.6 11.5 Boys 5.3 12.4 White 5.3 13.1 Black 6.0 12.1 White, non-Hispanic 4.5 11.8 Black, non-Hispanic 6.1 12.5 Mexican-American 7.7 14.8 Girls 6.0 10.7 White 5.4 10.2 Black 10.2 15.9 White, non-Hispanic 5.4 9.3 Black, non-Hispanic 10.5 15.8 Mexican-American 9.3 13.7
*--*
Overweight is defined as at or above the age- and sex-specific 95th percentile on the body mass index (a mathematical relationship between height and weight).
Source: Centers for Disease Control and Prevention’s National Center for Health Statistics
