By Jennifer Cheng

Children’s health care has changed a great deal since I started practicing pediatrics in the mid-1970s. On one hand, there have been tremendous medical advances that are great news for children’s health, such as the introduction of a vaccine to prevent chicken pox and the development of effective new medications to fight everything from asthma to teenage depression. But I’ve also seen a troubling trend--more children than ever are developing weight problems at a young age.

That excess weight can cause numerous physical problems, including early heart disease and type 2 diabetes, as well as psychological and self-esteem problems--as in the case of one of my young patients, nine-year-old Bennett. At his checkup a few days ago Bennett’s mom, Mrs. Robinson, asked me how she could help him lose weight. “The kids at school make fun of him,” she says, “and I’m afraid that if he’s overweight now the problem will just get worse as he gets older.”

I told Mrs. Robinson that the weight by itself is not my concern--it is the lifestyle around the weight issue that is generally the problem. Simple steps such as cutting back on TV time and eliminating junk food can help children lose weight and change their lives for the better. As children exercise more and eat healthier food, they will be slimmer and happier--and, in the long run, much healthier.

Below, Duke pediatrician Jennifer Cheng, MD, discusses some of the things parents can do to help their children adopt healthier lifestyles.

--Dennis Clements, MD, PhD

Dr. Cheng

Childhood obesity: A “big” problem

America is becoming a “super-sized” nation: everything from meals to clothing can now be found in ever-increasing sizes. Currently two out of three American adults and one of three American children and adolescents are obese or overweight--and rates are likely to continue to rise if current trends continue.

Although the exact causes of the obesity epidemic have yet to be determined, it’s likely the culprit is a combination of genetic and environmental factors, including a trend towards lower physical activity levels and poor eating habits.

A changing environment

We live in an environment that, while offering innumerable modern conveniences, is vastly different from that for which the human body was designed. Our bodies’ sophisticated mechanisms to conserve energy in a time of limited resources betray us in an era of relative bounty and energy surplus.

Many environmental factors compound the problem--urban sprawl that requires people to drive instead of walk; unsafe neighborhoods that discourage outdoor play; lack of recreational opportunities; and, in some locales, poor availability of healthful foods.

Economic factors are also important. For instance, while vending machines in school often dispense junk food, their proceeds can provide a substantial source of revenue to support important student services in many financially-strapped school districts.

On a separate front, the President’s “No Child Left Behind” policy has resulted in an increased emphasis on academic performance, sometimes to the detriment of other “non-essential” programs such as physical education.

The combination of easily available, high-calorie food and fewer opportunities to exercise makes it easier for children to gain weight. That’s because maintaining a constant weight requires that the amount of energy in the food consumed be equivalent to the amount of energy spent through physical activity. Regularly eating an excess of 100-150 calories per day (the equivalent of a small cookie), for example, can result in a 10- to 15-pound weight gain over the course of a year if those calories are not burned up through physical activity. Two extra cookies per day could potentially result in a 20- to 30-pound weight gain over a year!

What can families do to help children lead healthier lives?

Parents and other family members can play an important role in ensuring that children adopt and maintain healthful lifestyles despite the many obstacles present in their environment. Below are some recommendations:

Nutrition

• Pregnancy: Women who are pregnant should eat a sensible diet and avoid smoking and drinking alcohol. In addition, they should take a prenatal vitamin to ensure adequate nutrient levels, and see their doctors on a regular basis.
• Infants: Breast milk is uniquely tailored to meet all of the baby’s nutritional needs for the first six months of life. In addition, breastfeeding confers many health benefits, including lower rates of asthma, allergies, ear infections, intestinal problems, diabetes, and obesity. The American Academy of Pediatrics encourages mothers to exclusively breastfeed for the first six months (about the time the baby’s diet begins to include solid foods), and to continue breastfeeding for at least 12 months or as long as baby and mother want to continue.
• Children and adolescents: American kids and youth are bombarded with television advertising. Over 50 percent of television ads are for processed foods, most of which are high in saturated fat and simple sugars but low in fiber and protein. Families should discuss advertising tactics, and teach their children to be educated, health-conscious consumers.

Other dietary recommendations include:

• Eat breakfast every day! Studies have shown that kids who eat breakfast do better in school, are less likely to make poor lunch choices, and less likely to be overweight. Regularly eating meals at home with the family has also been shown to be associated with similar benefits.
• Eat out less frequently. For the most part, meals eaten away from home tend to be higher in fat and calories. However, healthier choices are generally available even at fast-food restaurants.
• Provide plenty of fruits and vegetables (aim for at least five servings per day) to promote your family’s intake of fiber and vitamins.
• Main dishes should emphasize complex carbohydrates (such as brown rice, beans, whole grains, and pasta).
• Trim all fat from meat before cooking.
• Use cooking methods that require little or no fat, such as broiling, steaming, and roasting.
• Limit sweetened beverages; encourage plain water instead.
• Plan snacks ahead of time to ensure that they are nutritious. Do not spoil your child’s appetite by offering snacks too close to mealtimes.
• Discourage snacking while watching television, which can lead to a habit of overeating.
• Know what is being served to children away from home (at school, grand-parent’s, neighbor’s home, etc.); voice your concern if the food is not nutritious.
• Consider bringing food from home if food choices do not meet nutritional standards.
• Understand and monitor serving sizes.
• Do not use food as a reward or punishment.

Exercise

By most accounts, American children are less active today than they were 20 years ago. One study has found that fewer than 25 percent of children in grades four through 12 participate in 20 minutes of vigorous activity or 30 minutes of any physical activity every day. Experts recommend that children get at least 60 minutes of physical activity each day for optimal health; adults should aim for at least 30 minutes of strenuous activity on most days of the week.

Some tips for becoming more active include:

• Be a role model. Children are more likely to adopt and maintain active lifestyles if they see that their parents are active and enjoying it!
• Limit sedentary activities. Studies show that kids who spend more than two hours a day watching television are more likely to be obese. The American Academy of Pediatrics recommends that kids spend no more than one to two hours a day watching TV or playing computer or video games. (Only non-violent games should be chosen).
• Walk more. If possible, bike or walk to school or to the store; take the stairs instead of the elevator.
• Help your child find physical activities that he or she enjoys and that aren’t too difficult.
• Offer activities, not food, as rewards. For example, go bowling for a treat rather than staying home to make double hot-fudge sundaes. On weekends, opt for active family outings such as hiking, swimming, or mall-walking rather than going to the movies and eating buttered popcorn.
• Push your local school board to make physical education a priority. Also push for nutritious school lunches and healthy choices in vending machines.
• Finally, make sure that your child is getting enough rest and sleep.

Hopefully, these tips will help you develop and foster an environment that will lead to healthier lives for you and your family.

Reference

American Academy of Pediatrics: Guide to Your Child’s Nutrition. Editors: William H. Dietz, MD, PhD and Lorraine Stern, MD. 1999.

Jennifer Cheng, MD - whose research interests include pediatric nutrition and obesity.

Dennis Clements, MD, PhD, is the chief of primary care pediatrics at Duke Children's Hospital.