America is experiencing a public health crisis involving overweight and obesity. Particularly alarming is the further evidence that the obesity epidemic involves American children and youth, as nearly one in three are classified as overweight or obese. Childhood obesity and overweight is a serious health concern in the United States because of immediate health consequences, as well as because it places a child at increased risk of obesity in adulthood, with all its attendant health problems such as cardiovascular diseases and type 2 diabetes. All adults-parents, educators, caregivers, teachers, policy makers, health care providers, and all other adults who work with and care about children and families-serve as role models in some capacity and share responsibility for helping the next generation prevent obesity by promoting healthy lifestyles at all ages.

Primary prevention of obesity, starting in pregnancy and early childhood, is the single best strategy for combating and reversing America's obesity epidemic for current and future generations. While there is also an urgent need to improve the health and well-being of children and adults who are already overweight and obese, primary prevention offers the strongest universal benefits. Solving the obesity problem will take a coordinated system-wide, multi-sectoral approach that engages parents as well as those in education, government, healthcare, agriculture, business, advocacy and the community. This approach must promote primary prevention among those who are not yet overweight and address weight loss and fitness among those who are overweight.

The Academy of Nutrition and Dietetics (AND) has taken an active role in solving the problem of childhood obesity with the introduction of the Kids Eat Right initiative. The key to reducing the prevalence of childhood obesity is good nutrition - but it's more than simply eating the recommended number of servings from all food groups. Parents and care-givers play a vital role in children's nutrition: they teach children about healthy foods, practice what they teach and make sure physical activity is incorporated into each day.

Course Objectives

At the conclusion of this program the dietetics professional will be able to:

1. Discuss childhood obesity terminology and definitions
2. Describe the prevalence of childhood obesity and the economic cost
3. Identify the medical complications associated with childhood obesity
4. Identify the multi-factorial causes of childhood obesity
5. Discuss medical assessment and weight management guidelines
6. Identify the solutions for reducing childhood obesity
7. Identify children's nutritional needs and dietary plan

Section II. Childhood Obesity Terminology and Prevalence

Obesity and Overweight Terminology

A variety of different terms, metrics, and cut-off values have been used to describe and assess overweight and obesity in children. Body mass index (BMI) calculated as weight in kilograms divided by height in meters squared can be used to express weight adjusted for height. In order to account for variability by sex and age, BMI in children is compared to sex-and age-specific reference values. In the United States, the Centers for Disease Control and Prevention (CDC) 2000 growth charts serve as reference values.

The CDC recommends the use of BMI and defined overweight as a BMI-forage at or above the 95th percentile of a specified reference population and the designation of ''at risk for overweight'' for BMI values between the 85th and the 95th percentiles of BMI for age. More recently, although the cut-off values and the interpretation have not changed, changes in terminology were proposed. An American Medical Association expert committee report retained the two cut-off values of the 85th and 95th percentiles of BMI-for-age but used different terminology, referring to BMI-for-age from the 85th up to the 95th percentile as ''overweight'' and to BMI-for-age at or above the 95th percentile as ''obesity.'' The National Center for Health Statistics (NCHS) and other CDC publications will continue to include prevalence estimates at the 85th and 95th percentiles as before but will change the terminology to use the term ''overweight'' for a BMI-for-age between the 85th and 95th percentile (formerly called ''at risk for overweight'') and the term ''obesity'' for a BMI-for-age at or above the 95th percentile (formerly called ''overweight'').¹

The CDC recognizes that it has been customary to use the term ''overweight'' instead of ''obese'' to refer to children with BMI values above the age-and gender-specific 95th percentiles. However, the term ''obese'' more effectively conveys the seriousness, urgency, and medical nature of this concern than does the term ''overweight,'' thereby reinforcing the importance of taking immediate action.

In recognition of the importance of language, the CDC also recommended the use of more ''neutral'' terms when discussing weight issues with families. Therefore, they recommend the use of the clinical terms 'overweight' and 'obesity' for documentation and risk assessment but the use of different terms in the clinician's office, to avoid an inference of judgment or repugnance.

Assessing if a child is at a healthy weight is complex. While BMI is often utilized, clinical assessment and other markers should be considered when determining a child's overall health and development. Children and adolescents with a BMI at or above the sex-and age-specific 95th percentile of this reference population are often considered obese, and those with a BMI between the 85th and 94th percentiles are often considered overweight. Although these cut-off points are not diagnostic criteria, elevated BMI among children most often indicates increased risk for future adverse health outcomes and/or development of disease.

According to the CDC the term ''obesity'' is used for the prevalence of BMI-for-age at or above the 95th percentile. However, obesity strictly speaking refers to excess body fat and not to high BMI-for-age. Not all children at the BMI-for-age level labeled ''obesity'' necessarily have excess body fat and some children below that level may have excess body fat. For children, there is no precise widely accepted definition of obesity in terms of body fatness.

The following chart is an example of the Stature-for-age and Weight-for-age percentiles for Boys Aged 2-20:

Obesity Prevalence Among Children and Adolescents

Healthy People 2010 identified overweight and obesity as 1 of 10 leading health indicators and called for a reduction in the proportion of children and adolescents who are overweight or obese, but the United States has made little progress toward the target goal. Progress toward reducing the national prevalence of overweight and obesity is monitored using data from the National Health and Nutrition Examination Survey (NHANES).

Results from the 2007-2008 NHANES, using measured heights and weights, indicate that an estimated 16.9% of children and adolescents aged 2-19 years are obese. Between 1976-1980 and 1999-2000, the prevalence of obesity increased. Between 1999-2000 and 2007-2008, there was no significant trend in obesity prevalence for any age group.³

Body mass index (BMI), expressed as weight in kilograms divided by height in meters squared (kg/m2), is commonly used to classify obesity among adults, and is also recommended in children. Cutoff criteria are based on the 2000 CDC BMI-for-age-growth charts for the United States. Based on current recommendations of expert committees, children with BMI values at or above the 95th percentile of the sex-specific BMI growth charts are categorized as obese. This is different from previous years where children above this cutoff were labeled overweight. Although this cutpoint is not diagnostic, elevated BMI among children indicates increased risk for future adverse health outcomes or development of disease.

The following charts shows the trends in obesity among children and adolescents since the 1960s by age group.

Racial and Ethnic Disparities in Adolescent Obesity

Based upon the findings from the National Health and Nutrition Examination Survey (NHANES), there are significant racial and ethnic disparities in obesity prevalence among U.S. children and adolescents. In 2007-2008, the prevalence of obesity was significantly higher among Mexican-American adolescent boys (26.8%) than among non-Hispanic white adolescent boys (16.7%). In NHANES III (1988-1994) there was no significant difference in prevalence between Mexican-American and non-Hispanic white adolescent boys.

• From 11.6% to 16.7% among non-Hispanic white boys.
• From 10.7% to 19.8% among non-Hispanic black boys.
• From 14.1% to 26.8% among Mexican-American boys.

Among girls in the period 2007-2008, non-Hispanic black adolescents (29.2%) were significantly more likely to be obese compared with non-Hispanic white adolescents (14.5%). Similarly, non-Hispanic black adolescent girls (16.3%) were more likely to be obese compared with non-Hispanic white adolescent girls (8.9%) in the period 1988-1994.

Between 1988-1994 and 2007-2008 the prevalence of obesity increased:

• From 8.9% to 14.5% among non-Hispanic white girls.
• From 16.3% to 29.2% among non-Hispanic black girls.
• From 13.4% to 17.4% among Mexican-American girls.

National Health and Nutrition Examination Survey (NHANES)

NHANES used stratified, multistage, probability samples of the civilian noninstitutionalized U.S. population. A household interview and a physical examination were conducted for each survey participant. During the physical examination, conducted in a mobile examination center, height and weight were measured as part of a more comprehensive set of body measurements. These measurements were taken by trained health technicians, using standardized measuring procedures and equipment. Observations for persons missing a valid height or weight measurement or for pregnant females were not included in the data analysis.

Section III. Complications of Childhood Obesity

Medical Problems

The Childhood Obesity Foundation reports that obese children can develop serious health problems, such as diabetes and heart disease, often carrying these conditions into an obese adulthood. Obesity in childhood may result in serious medical problems in childhood such as:⁴

• Type 2 diabetes
• High blood pressure and elevated blood cholesterol
• Metabolic syndrome: a number of conditions that are all associated with high blood insulin levels including type 2 diabetes and high blood pressure
• Liver disease
• Bone and joint problems
• Respiratory problems such as asthma
• Sleep disorders such as difficulty breathing while asleep (sleep apnea)
• Earlier than normal puberty or menstruation
• Eating disorders such as anorexia or bulimia
• Skin infections due to moisture from sweat being trapped in skin folds
• Fatigue

Overweight or obesity in childhood can also result in serious psychological difficulties. Overweight or obese children:

• Are more likely to be teased and bullied
• Are more likely to bully others
• May have poor self-esteem and may feel socially isolated
• May be at increased risk for depression
• May have poorer social skills
• May have high stress and anxiety
• May have behavior and/or learning problems as a result of psychological difficulties related to childhood obesity

Unfortunately most obese children and youth do not outgrow their weight problem. Most people continue to gain weight as they age.

The CDC reports that diabetes is one of the most common chronic diseases among children in the United States. When diabetes strikes during childhood, it is routinely assumed to be type 1, or juvenile-onset diabetes. Type 1 diabetes develops when the body's immune system destroys pancreatic cells that make the hormone insulin that regulates blood sugar. It normally strikes children and young adults. People with type 1 diabetes must have daily insulin injections to survive.⁵

In the last two decades, type 2 diabetes, formerly known as adult-onset diabetes, has been reported among U.S. children and adolescents with increasing frequency. Type 2 diabetes begins when the body develops a resistance to insulin and no longer uses the insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce sufficient amounts of insulin to regulate blood sugar.

In 2001 the CDC began a study of approximately 3.5 million children less than 20 years of age to estimate how many children or young people had Diabetes Mellitus (DM) (prevalent cases). Their estimate for DM prevalence was 1.8 per 1,000.

Prevalence data indicate that in the U.S., at least 154,000 children/youth have DM. DM prevalence varies across major racial/ethnic groups:

• In children 0-9 years of age non-Hispanic whites have the highest prevalence (about 1/1,000). In this age group across all race/ethnic groups, type 1 DM is the most common form of diabetes. The study found that type 2 DM is extremely rare in children of all races younger than 10 years of age.
• Among adolescents and young adults (age 10-19 years), African American and non-Hispanic white youth have the highest burden of DM (about 1 of 315) and Asian/Pacific Islanders have the lowest (about 1 of 746).Type 1 DM prevalence is 2.3/1,000 and it is the most common form of DM in all racial/ethnic groups except in American Indian youth. Type 2 prevalence is 0.4/1,000 and it represented 6% of the cases of diabetes in Non-Hispanic White, 33% in African American, 40% in Asian/Pacific Islander, and 76% among American Indian youth.

Since 2002, approximately 5.5 million children less than 20 years of age (approximately 6 percent), each year have been under surveillance to estimate how many children/youth develop diabetes (incidence cases) per year.

Based on 2002 and 2003 data, the overall incidence is estimated to be 24.3 per 100,000 per year. Annually, an estimated 15,000 youth are diagnosed with type 1diabetes, and about 3,700 youth are diagnosed with type 2.

• Among youth aged <10 years, most diabetes cases are type 1, regardless of race/ethnicity. In this age group the highest incidence of type 1 diabetes is observed in non-Hispanic whites (19/100,000 for 0- to 4- years-old and 28/100,000 for 5- to 9- years-old)
• Among older youth (ages 10-14 and 15-19 years), the highest incidence of type 1 diabetes is in non-Hispanic white youth (33/100,000 per year for 10- to 14- years-old and 15/100,000 for 15- to 19- year olds), followed by African American (19.2 and 11.1) and Hispanic (17.6 and 12.1), and lowest among American Indian (7.1 and 4.8) and Asian/Pacific Islanders (8.3 and 6.8).
• The incidence of type 2 DM is the highest among American Indians (25.3 and 49.4 for ages 10-14 and 15-19 years, respectively), followed by African Americans (22.3 and 19.4), Asian/Pacific Islanders (11.8 and 22.7) and Hispanics (8.9 and 17.0), and is low (3.0 and 5.6) among non-Hispanic whites.

The study has shown that nutritional intake in adolescents with DM is poor and does not follow current recommendations. Recommendations for total dietary fat intake are met by only 10 percent of youth with DM and recommendations for saturated fat intake by only 7 percent.

It was found that about 9 percent of adolescents with DM have moderate or severely depressed mood symptoms, with more girls than boys being affected. Depressed mood is associated with poor glycemic control and a higher likelihood of emergency room visits.

Cardiovascular Disease Risks

The National Center for Chronic Disease Prevention and Health Promotion reports that obese youth are more likely to have risk factors for cardiovascular disease, such as high cholesterol or high blood pressure. In a population-based sample of 5- to 17-year-olds, 70% of obese youth had at least one risk factor for cardiovascular disease.⁶

A study by The American Academy of Pediatrics found that of overweight children and adolescents in Bogalusa, Louisiana, over half of overweight children and adolescents had at least one additional risk factor for cardiovascular health problems. The analysis was based upon seven studies conducted which included more than 9,100 5- to 17-year-olds.⁷

• " Fifty-eight percent of the overweight school children, including children 5 to 10 years old, were found to have at least one additional cardiovascular risk factor.
• " Twenty percent of the overweight children and adolescents had two or more additional cardiovascular risk factors.

As compared with average weight children and adolescents, overweight youth were found to be:

• 2.4 times more likely to have an elevated level of total cholesterol
• 2.4 times more likely to have elevated diastolic blood pressure
• 4.5 times more likely to have higher systolic blood pressure
• 3 times more likely to have adverse levels of low-density lipoprotein (LDL) cholesterol, and 3.4 times more likely to have adverse high-density lipoprotein (HDL) cholesterol
• 7 times more likely to have elevated triglyceride levels
• 12.6 times more likely to have elevated fasting insulin levels
• Asthma

Asthma

The relationships, interactions, and association between obesity and asthma are complex. Being overweight has been associated with an increased risk of new-onset asthma in boys and in children without allergy. Asthma is a risk for obesity in urban minority children and adolescents. Extensive reviews of the association between asthma and obesity, describe potential associative relationships that rely on genetics, immune system modification, and mechanical mechanisms. On the basis examination of the current evidence:⁸

• Obesity has been associated with increases in the incidence and prevalence of asthma in several epidemiological studies of adults and children
• Weight loss in obese subjects results in an improvement in overall pulmonary function and asthma symptoms, as well as decreases in asthma medication usage
• Obesity may directly affect the asthma phenotype by mechanical effects including airways latching and cytokine modulation via adipose tissue, through common genes or genetic regions, or by sex-specific effects including the hormone estrogen
• Obesity may also be related to asthma by genetic interactions with environmental exposures, including physical activity and diet

Sleep Apnea

Sleep apnea is a less common complication of overweight for children and adolescents. Sleep apnea is a sleep-associated breathing disorder defined as the cessation of breathing during sleep that lasts for at least 10 seconds. Sleep apnea is characterized by loud snoring and labored breathing. During sleep apnea, oxygen levels in the blood can fall dramatically. One study estimated that sleep apnea occurs in about 7% of overweight children.⁹

Economic Costs

The U.S. Public Health Service reported the economic costs of obesity are staggering and second only to the cost of tobacco use. The national health care costs related to obesity have been estimated to range from $98 billion to $129 billion. A decade ago the estimated health care costs attributable to obesity ranged from 1 to 6 percent of the total health-care expenditures but now account for 9 percent.

The Centers for Disease Control and Prevention found that overweight children are being increasingly hospitalized for diabetes, sleep apnea and other diseases that obesity causes or worsens. This increase in numbers has made hospital costs related to childhood obesity more than triple in the past 20 years to $127 million. Dr. William Dietz, the CDC lead researcher, stated that this increase in hospitalization "changes the perspective that obesity is simply a cosmetic problem to really focus on…childhood obesity as a serious medical problem."¹⁰

The CDC researchers culled hospital discharge records, comparing obesity-related hospitalizations of 6 to 17 year olds over the past 20 years. They found that diagnoses of obesity tripled to reach 1% of hospitalizations. Sleep apnea rose fivefold and gallbladder disease tripled. Asthma cases complicated by obesity rose 40%.

The increasing numbers of obese children may be an understated figure because doctors often don't record obesity on hospital discharge records. Insurance companies usually don't pay to treat obesity unless the child has a formal illness.

Without effective intervention, the costs of obesity might well become catastrophic, arising not only from escalating medical expenses but also from diminished worker productivity, caused by physical and psychological disabilities. Future economic losses could mean the difference between solvency and bankruptcy for Medicare, between expanding and shrinking health care coverage, and between investment in and neglect of the social infrastructure, with profound implications for international competitiveness.

Psychological Risks of Childhood Obesity

Some consequences of childhood and adolescent overweight are psychosocial. Obese children and adolescents are targets of early and systematic social discrimination. The psychological stress of social stigmatization can cause low self-esteem which, in turn, can hinder academic and social functioning, and persist into adulthood.¹¹

All children have to construct an identity and a concept of themselves. Part of this construction involves monitoring how significant others, friends and peers respond to them, along with the value judgments that accompany those perceptions. This takes place in environments that are overlaid with cultural and societal attitudes, values and conformities. Overweight and obese children develop a sense of self, self-esteem and cope with the consequences of their body status against this back-drop.¹²

Consequences of Childhood Obesity

The consequences of obesity are many and varied for children (and their families). These can range from a dislike of PE to the family moving home because of bullying, or from indifference to feeling depressed and suicidal. Overweight children may be labeled as immature or disruptive when they are behaving normally for their age, but their appearance is up to three years older. Parents, particularly mothers, may be perceived as fussy, over-protective or to blame, which impacts on the whole family.

Section IV. Multi-Factorial Causes of Childhood Obesity

Understanding the Causes of Childhood Obesity

Understanding the causes of childhood obesity can provide the opportunity to focus resources, interventions and research in directions that would be most beneficial in addressing the problem.¹³

The causes of childhood obesity are multi-factorial. Overweight in children and adolescents is generally caused by a lack of physical activity, unhealthy eating patterns resulting in excess energy intake, or a combination of the two. Genetics and social factors - socio-economic status, race/ethnicity, media and marketing, and the physical environment - also influence energy consumption and expenditure. Most factors of overweight and obesity do not work in isolation and solely targeting one factor may not going to make a significant impact on the growing problem.

To date, research has been unable to isolate the effects of a single factor due to the co-linearity of the variables as well as research constraints. Specific causes for the increase in prevalence of childhood obesity are not clear and establishing causality is difficult since longitudinal research in this area is limited. Such research must employ long study times to discern if there is an interaction of factors leading to an increase in the prevalence or the prevention of obesity during childhood and adolescence. Underreporting total food intake, misreporting of what was eaten, and over reporting physical activity are all likely potential biases that may affect the outcomes of studies in this area.

Nutrition and Eating Habits

It is difficult to correlate nutritional choices and childhood obesity using observational research. However, trend data suggest some changes in eating patterns and consumption that may be correlated with increases in obesity. In general, children and adolescents are eating more food away from home, drinking more sugar-sweetened drinks, and snacking more frequently. Convenience has become one of the main criteria for American's food choices today, leading more and more people to consume 'away-from-home' quick service or restaurant meals or to buy ready-to-eat, low cost, quickly accessible meals to prepare at home. The nutritional composition of children's diets as well as the number of calories consumed are of interest to determine the effect of food consumption on childhood obesity.

Below are notable trends gleaned from studies that used the USDA's Nationwide Food Consumption Survey and the Continuing Survey of Food Intakes by Individuals. These studies demonstrate changes in eating patterns among American youth that illustrate the complexity that exists relating food intake to the increased prevalence of obesity.

• Children are getting more of their food away from home. Energy intake from away-from-home food sources increased from 20 to 32 percent from 1977-1978 to 1994-1996.¹⁴
• Daily total energy intake did not significantly increase for children 6-11, but did increase for adolescent girls and boys (ages 12-19 years) by 113 and 243 kilocalories, respectively.¹⁵
• Daily total energy intake that children derived from energy dense (high calorie) snacks increased by approximately 121 kilocalories between 1977 and 1996. ¹⁶
• There has been a decline in breakfast consumption - especially for children of working mothers.
• Portion sizes increased between 1977 and 1996. Average portion sizes increased for salty snacks from 1.0 oz to 1.6 oz and for soft drinks from 12.2 oz to 19.9 oz.¹⁷

Other studies indicate that children are not eating the recommended servings of foods featured in the USDA food pyramid and that there have been significant changes in the types of beverages that children are consuming:¹⁸

• Only 21 percent of young people eat the recommended five or more servings of fruits and vegetables each day. As shown in figure 2, nearly half of all vegetable servings are fried potatoes.
• Percent total energy from fat actually decreased between 1965 and 1996 for children, from 39 to 32 percent for total fat, and 15 to 12 percent for saturated fat.
• In 1994-1996, adolescent girls and boys only consumed 12 and 30 percent, respectively, of the Food Guide Pyramid's serving recommendations for dairy; and 18 and 14 percent, respectively, of the serving recommendations for fruit.
• Soda consumption increased dramatically in the early to mid 1990s. Thirty-two percent of adolescent girls and 52 percent of adolescent boys consume three or more eight ounce servings of soda per day. Soft drink consumption for adolescent boys has nearly tripled, from seven to 22 oz. per day (1977-1978 to 1994). Children as young as seven months old are consuming soda. ¹⁹
• Milk consumption has declined during the same period. In 1977-78, children age 6-11 drank four times as much milk as any other beverage. In 1994-1996 that decreased to 1.5 times as much milk as sugar sweetened beverages. In 1977-1978, adolescents drank 1.5 times as much milk as any other beverage and in 1996 they consumed twice as much sugar sweetened beverages as milk. Milk consumption decreased for adolescent boys and girls 37 and 30 percent respectively, between 1965 and 1996.

Physical Inactivity and Sedentary Behaviors

Research indicates that a decrease in daily energy expenditure without a concomitant decrease in total energy consumption may be the underlying factor for the increase in childhood obesity. Physical activity trend data for children are limited, but cross sectional data indicates that one third of adolescents are not getting recommended levels of moderate or vigorous activity, 10 percent are completely inactive, and physical activity levels fall as adolescents age. This situation may actually be worse than these data describe. Activity measured by physical activity monitors tends to be significantly lower than what is reported on surveys.²⁰

Watching television, using the computer, and playing video games occupy a large percentage of children's leisure time, influencing their physical activity levels. It is estimated that children in the United States are spending 25 percent of their waking hours watching television and statistically, children who watch the most hours of television have the highest incidence of obesity. This trend is apparent not only because little energy is expended while viewing television but also because of the concurrent consumption of high-calorie snacks.

A recent examination of the Department of Education's Early Childhood Longitudinal Survey (ECLS-K) found that a one-hour increase in physical education per week resulted in a 0.31 point drop (approximately 1.8%) in body mass index among overweight and at-risk first grade girls. There was a smaller decrease for boys. The study concluded that expanding physical education in kindergarten to at least five hours per week could reduce the percentage of girls classified as overweight from 9.8 to 5.6 percent.

Percentage of children aged 9-13 years who reported participation in organized and free-time physical activity during the preceding 7 days, by selected characteristics

Currently, schools are decreasing the amount of free play or physical activity that children receive during school hours. Only about one-third of elementary children have daily physical education, and less than one-fifth have extracurricular physical activity programs at their schools. Daily enrollment in physical education classes among high school students decreased from 42 percent in 1991 to 25 percent in 1995, subsequently increasing slightly to 28 percent in 2003. Outside of school hours, only 39 percent of children ages 9-13 participate in an organized physical activity, although 77 percent engage in free-time physical activity.²¹

Physical Environment

Experts have increasingly looked to the physical environment as a driver in the rapid increase of obesity in the United States. In urban and suburban areas, the developed environment can create obstacles to being physically active. In urban areas, space for outdoor recreation can be scarce, preventing kids from having a protected place to play; neighborhood crime, unattended dogs, or lack of street lighting may also inhibit children from being able to walk safely outdoors; and busy traffic can impede commuters from walking or biking to work as a means of daily exercise. Though few studies are available on the direct effects of the physical environment on physical activity, there are signs of the potential for improvement, evidenced by Toronto's 23 percent increase in bicycle use after the addition of bike lanes, and London's footpath use increase within the range of 34-101 percent (depending on location) as a result of improved lighting.

There has been less research on the relationship between the physical environment and physical activity for children than for adults, however the findings for children appear to be consistent with those of the adult population. The percentage of trips to school that children walked declined from 20 percent in 1977 to 12 percent in 2001. Because children spend a substantial amount of time traveling to and from school, this may be an area in which to incorporate and increase physical activity into children's daily habits. Additionally, in-school environments have an impact on children's health. In a study of available school environments such as courts, fields and nets for physical activity in middle schools, environmental characteristics including the area type and size, supervision, temperature and organized activities explained 42 percent of the variance in the proportion of girls who were physically active and 59 percent of the variance in boys.²²

In suburban areas, the evolution of 'sprawl' can prevent residents from walking or biking and contributes to the great dependence on rising vehicle use. Suburban residents frequently lack adequate resources for physical recreation or sidewalks. In the first national study to establish a direct association between the form of the community and the health of the people who live there, analysts from Smart Growth America and the Centers for Disease Control and Prevention (CDC) found that "sprawl appears to have direct relationships to BMI and obesity.²³

Socio-Economic Status and Race/Ethnicity

Among adults, a negative relationship between Socioeconomic Status (SES) (e.g., parental income, parental education, occupation status) and being overweight or obese has been well established, however, the relationship appears weaker and less consistent in children. A number of studies find that SES is negatively associated with children being overweight or obese. It appears likely that the relationship between SES and obesity varies by race/ethnicity, such that the negative relationship is only apparent among White adolescents and is not apparent among Black or Mexican-American (and presumably other Latino) adolescents. In other words, Black and Latino children from families with higher socioeconomic status are no less likely to be overweight or obese than those in families with lower socioeconomic status.²⁴

Despite the more pronounced impact of SES among White children, they are substantially less likely to be overweight or obese than Black, Latino, or Native American children, who are disproportionately affected by obesity. Furthermore, the relationship among race/ethnicity, SES, and childhood obesity may result from a number of underlying causes, including less healthy eating patterns (e.g., eating fewer fruits and vegetables, more saturated fats), engaging in less physical activity, more sedentary behavior, and cultural attitudes about body weight. Clearly these factors tend to co-occur and are likely to contribute jointly to differentials in increased risk of obesity in children.

Parental Influences

Numerous parental influences shape the eating habits of youth including; the choice of an infant feeding method, the foods they make available and accessible, the amount of time children are left unsupervised and their eating interactions with others in the social context. Several studies suggest that breastfeeding offers a small but consistent protective effect against obesity in children.²⁵

This effect is most pronounced in early childhood. It has been hypothesized that exposure to complex sugars and fats contained in bottle formula influence "obesogenic factors" in infants, which predispose them to weight gain later on in life. A recent study postulated that breastfeeding may promote healthier eating habits because breastfed infants may eat until satiated, whereas bottle fed babies may be encouraged to eat until they have consumed all of the formula. Breast feeding also may expose babies to more variability in terms of nutrition and tastes since formula fed infants have experience with only a single flavor, whereas breastfed infants are exposed to a variety of flavors from the maternal diet that are transmitted through the milk.

Studies suggest that parental food preferences directly influence and shape those of their children. Parents who ate diets high in saturated fats also had children that ate diets high in saturated fats. It is suspected that this observation is not merely due to the foods parents feed their children, but rather due to the preferences children develop through exposure to foods that their parents prefer early in their lives. Exposure to fruits and vegetables and foods high in energy, sugar and fat may play an important role in establishing a hierarchy of food preferences and selection in kids. Other studies have confirmed that availability and accessibility of fruits and vegetables was positively related to fruit and vegetable preferences and consumption by school children.²⁶

Additionally, child-feeding practices that control what and how much children eat can also affect their food preferences. Studies have determined that parents who attempt to encourage the consumption of food(s) may inadvertently cause children to dislike the food(s). Whereas parents that attempt to limit food(s) may actually promote increased preference and consumption of the limited food(s) in children.

Over the last three decades there has been an increase in the number of dual income families as more women have entered the workforce and there has been an increase in the number of women serving as the sole supporter for their families. It has been hypothesized that increased rates and hours of parental employment may be correlated with the weight increases in American children (particularly for women because they still bear the bulk of the responsibility of caring for children). Studies have demonstrated that children in single-parent families are more likely to be overweight or obese than children in two-parent families and that the rise in women working outside the home coincides with the rise in childhood weight problems. Several potential mechanisms have been proposed to explain this phenomenon including the following:

• Constraints on parent's time potentially contribute to children's weight problems, as working parents probably rely more heavily than non-working parents on prepared, processed, and fast foods, which generally have high calorie, high fat, and low nutritional content.
• Children left unsupervised after school may make poor nutritional choices and engage in more sedentary activities.
• Child care providers may not offer as many opportunities for physical activity and may offer less nutritious food alternatives.
• Unsupervised children may spend a great deal of time indoors, perhaps due to safety concerns, watching TV or playing video games rather than engaging in more active outdoor pursuits.

In short, the recent social and economic changes in American society have encouraged the consumption of excess energy and have had a detrimental effect on energy expenditure among youth. These changes have impacted the foods available in the homes, the degree of influence parents have when children make food selections and has led to increases in sedentary behaviors among youth.

Genetics

There is some evidence that supports genetic susceptibility as an important risk factor for obesity. Evidence from twin, adoption and family studies strongly suggests that biological relatives exhibit similarities in maintenance of body weight, and that heredity contributes between five and 40 percent of the risk for obesity. Other studies indicate that 50-70 percent of a person's BMI and degree of adiposity (fatness) is determined by genetic influences and that there is a 75 percent chance that a child will be overweight if both parents are obese, and a 25-50 percent chance if just one parent is obese.²⁷

Though this relationship is well established, the role of genetics in obesity is complex. While over 250 obesity-associated genes have been identified, there is no one 'smoking gun'. Cases of monogenic obesity and related syndromes do exist, but they are extremely rare and only account for a small number of those who are overweight and obese. To date only six single gene specific defects that result in obesity have been found, and appear to affect fewer than 150 people. Genetic susceptibility to obesity in most cases is due to multiple genes that interact with environmental and behavioral factors. Simply having a genetic predisposition to obesity does not guarantee that an individual will develop the disease.

It must also be noted that the recent increases in weight observed in the American population are not correlated with genetics. Despite the strong influence that genetics has on obesity, the genetic composition of a population does not change rapidly, and moreover, the characteristics of the American population have not dramatically changed. Therefore, increases in the incidence and prevalence rates of obesity in the US are likely due to behavioral or environmental factors, which have interacted with genes, and not the effects of genetics alone.

Advertising and Marketing

There has been considerable debate over whether exposure to food advertising affects incidence rates of childhood obesity. While the positive correlation between the hours of television viewed, body mass index, and obesity incidence has been documented, the exact mechanisms through which this occurs are still being investigated. It has been estimated that the average child currently views more than 40,000 commercials on television each year, a sharp increase from 20,000 in the 1970s. Moreover, an accumulated body of research reveals that more than 50 percent of television advertisements directed at children promote foods and beverages such as candy, convenience foods, snack foods, sugar sweetened beverages and sweetened breakfast cereals that are high in calories and fat and low in fiber and nutrient density. The statistics on food advertising to children indicate that:²⁸

• Annual sales of foods and beverages to young consumers exceeded $27 billion in 2002.
• Food and beverage advertisers collectively spend $10 to $12 billion annually to reach children and youth: more than $1 billion is spent on media advertising to children (primarily on television); more than $4.5 billion is spent on youth-targeted public relations; and $3 billion is spent on packaging designed for children.
• Fast food outlets spend $3 billion in television ads targeted to children.

A growing body of research suggests that there may be a link between exposure to food advertising and the increasing rates of obesity among youth. In the 1970s and 1980s a number of experimental studies were conducted that demonstrated young children (under age eight) were much more likely than older children to believe that television advertisements were telling the truth; and that exposure to television advertisements influenced the food choices among children (enticing them to choose more sugary foods instead of natural options) which increased requests to parents for high sugar foods they saw advertised. Though many of these studies did find significant correlations between advertising and behavioral change, the reliability of these findings are equivocal because many of the studies use small sample sizes, and some of them are more than 25 years old.

A recent literature review by Kaiser Family Foundation highlighted a number of studies that suggested that advertising influenced dietary and other food choices in children, which likely contributed to energy imbalance and weight gain. One study found that among children as young as three, the amount of weekly television viewing was significantly related to their caloric intake as well as requests and parental purchases of specific foods they saw advertised on television. Several other studies found that the amount of time children spent watching TV was correlated with how often they requested products at the grocery store and their product and brand preferences.

Pediatricians, child development experts, and media researchers have theorized that media may contribute to childhood obesity in one or more of the following ways:

• The time children spend using media displace time they could spend in physical activities
• The food advertisements children are exposed to on TV influence them to make unhealthy food choices.
• The cross-promotions between food products and popular TV and movie characters are encouraging children to buy and eat more high-calorie foods
• Children snack excessively while using media, and they eat less healthy meals when eating in front of TV
• Watching TV and videos lower children's metabolic rates below wha they would be even if they were sleeping
• Depictions of nutrition and body weight in entertainment media encourage children to develop less health diets.

Those who discount the idea that advertising is a factor in childhood obesity cite the limited research findings, question the methodological validity of much of the available literature and look to observational outcomes of policy changes in Canada and Sweden. In 1980, Quebec banned all food advertising to children; however the rates of obesity for children in Quebec are currently no different from those in other Canadian Provinces. A similar ban on advertising has existed in Sweden for over a decade, and also has not resulted in reductions of obesity rates. Though these observations undermine the conclusions of the Hastings review and others, no definitive answers are apparent. In order to close the loop on the causal pathway between food advertising and childhood obesity, many questions need to be answered using longitudinal studies designed with a sufficient statistical power.

Obesity - Sleep and TV

A Harvard University study found that babies and toddlers who sleep fewer than 12 hours daily were at greater risk for being overweight in preschool, evidence that the link between sleep and obesity may affect even very young children. TV viewing heightened the effect. The children who slept the least and watched the most television had the greatest chance of becoming obese. ²⁹

"The two (behaviors) are acting independently. In combination, they are particularly risky," said the study's lead author, Dr. Elsie Taveras of Harvard Medical School. The findings are based on mothers' reports of their babies' sleep habits and TV viewing, and direct measures of the children's height, weight and skinfold thickness.

TV viewing is thought to increase the risk of obesity both because it takes time away from calorie-burning play and because of food ads for snacks and fast food.

Section V. Medical Assessment and Weight Management Guidelines

Medical Assessment

The Health Resources and Services Administration, Maternal and Child Health Bureau recommends the weight for height status should be assessed by calculating BMI and comparing it to age- and gender-appropriate percentiles. Among children who have BMI values >85th percentile, an assessment of potential medical or psychosocial complications is needed.³⁰

A medical assessment which includes family history of obesity and chronic disease risk factors, measurements of blood pressure, blood sugar and blood lipids, a weight history, screening for depression, and a physical exam to rule out exogenous causes of overweight should be performed on all overweight youth.

When a child or adolescent has been diagnosed as at risk for overweight or overweight, an assessment of environmental factors known to contribute to obesity is recommended.

This usually starts with a nutrition assessment which should include a review of all medical and laboratory findings and an estimate of usual dietary intake. A dietary assessment should include:

• The number of eating occasions in a usual day
• Preferred or disliked foods
• Frequency of eating purchased foods (takeout, deli and restaurant foods)
• Any dietary restrictions or alterations that have been implemented to date
• Portions sizes of food served and eaten
• Frequency of consumption of foods high in fat and sugar as well as foods that are of low nutrient density

Physical activity level should be determined by the frequency and duration of moderate-to-strenuous physical activity as well as daily activities, such as walking to school.

Current recommendations are to participate in moderate activity on all or most days of the week and moderate to strenuous activity at least 3 days per week. A separate assessment of the frequency and duration of sedentary activities is also required.

If abuse, neglect or other psychosocial issues are suspected, a referral should be made to a mental health professional for an in-depth assessment. A mental health professional can also assess the child or adolescent for signs of depression, dysthymia, or eating disorders.

The type of treatment program recommended for overweight youth varies according to the needs of the individual as determined by physical and environmental assessments.

The following figure illustrates the recommended treatment goals based on a child's BMI and age. Weight loss should not be attempted until the family has shown that they can maintain the child's weight. For severely obese children, as well as those with significant medical complications, rapid weight loss may be required. Several pediatric obesity treatment centers have health professionals experienced in the management of severe obesity with complications.

The first step in the treatment of overweight among children is an assessment of readiness of the family to make behavior changes. This is done by asking members of the family about their concern regarding the child's weight, if they believe it is possible for the child to maintain or lose weight, and what behaviors they think need to be changed to facilitate weight management.

It is important to include all members of the family in weight management programs since the entire family must modify eating and activity patterns if weight loss or maintenance is to be achieved.

Parents who believe that their child is destined to be overweight or who are hesitant to adopt new behaviors to assist youth in weight management may benefit from counseling to motivate them to make behavior changes before a treatment program is started. A treatment program undertaken reluctantly by family members not ready to make behavior changes is very likely to result in failure to meet program goals.

General Guidelines for Weight Management

Unsuccessful attempts at weight management may lower self-esteem in overweight children and frustrate family members.

General Guidelines for Weight Management

• Early intervention is recommended, preferably before the child reaches the 95th percentile for BMI.
• Parents should be informed of medical complications associated with childhood overweight and all youth should be assessed for medical complications.
• All family members and caregivers should be involved in the weight management program.
• All family members should be assessed to determine their readiness to make behavior changes and treatment should not begin until all family members are ready to adopt behavior changes.
• Weight management programs should emphasize goals of improving eating and physical activity patterns as opposed to specific weight goals.
• Families should be taught to identify problem behaviors, monitor such behaviors, utilize behavior modification principles to address problem behaviors, and to utilize problem-solving skills when dealing with obstacles to behavior change.
• Families should be involved in assessing current eating and activity patterns, determining which behaviors need to be modified, setting goals for behavior changes, and determining how success of reaching these goals will be determined.
• New behavior changes should not be instituted until previous changes have been accomplished and maintained.
• Routine follow-up visits should be scheduled to monitor progress and prevent relapse to former eating and activity patterns.

It should be stressed to the child and family that the primary goal of a weight management program is to adopt healthier eating and activity habits, not to reach a specific weight. To accomplish this, weight management programs should emphasize the development of new skills by family members, including:

• Training on how to become more aware of current eating, activity and parenting patterns that contribute to overweight
• Assistance in identifying problem behaviors such as the consumption of specific foods or barriers to physical activity
• Behavior modification training so that families can make gradual, permanent changes in eating and activity patterns
• Problem solving skills so that families learn to deal with new barriers or issues that arise as the child continues to develop socially, mentally and physically.

Families should not be asked to make more than 2-3 behavior changes during the initial treatment visit. Goals should be set cooperatively by the family and health professional(s) and the family should be involved in determining how success will be measured. Additional changes should be negotiated and instituted only after the family has demonstrated success in achieving the initial changes.

It is imperative that the family be involved in determining what behavior changes will be made. This allows the health professional to teach skills in identifying problem behaviors, increases the family member's awareness of their own habits, and provides an opportunity for the health professional to teach behavior modification skills. It also provides a sense of ownership in the program on the part of family member, which may result in increased compliance.

Pediatric Weight Management Programs Guidelines

There are no standard physical activity or dietary regimens recommended for pediatric weight management programs. Reducing the intake of foods such as savory snacks or high-sugar beverages is often the first dietary change recommended. Calorie counting or counting fat grams is not recommended. Replacing high-fat or high-sugar foods with healthier alternatives and teaching portion control are tactics better accepted by families and are more likely to result in longer-term behavior changes. Replacing sedentary activities with more strenuous activities is a relatively easy first goal for changes in physical activity. Referrals to community centers, local parks and recreation programs, and community education programs can also be beneficial. However, it is up to the family to decide what changes they feel are achievable at any point in the treatment program.

Bi-weekly or weekly reviews of changes in dietary intake and physical activity as well as measurements of weight should occur, at the clinic or at home, to help the family members review treatment goals and assess their progress. Health professionals should learn to place the greatest emphasis on success experienced in making behavior changes and less emphasis on successful weight maintenance or loss.

It is important that the family maintain a regular schedule of visits with health professionals involved in weight management until a satisfactory weight for height has been achieved and all medical complications have been resolved. Follow-up visits at six-month intervals are recommended after the completion of a weight management program to monitor growth and development and to reinforce the newly adopted behaviors within the family setting.

Section VI. Solutions for Reducing Childhood Obesity

Reducing Obesity Occurrence

The CDC reports that the primary development of healthy weight programs for children and youth must be promoted from all segments of society. The obesity epidemic is a serious public health problem that needs immediate action to reduce its prevalence as well as its health and social consequences.

Government

Since the 1930's the federal government has made a commitment to programs that recognize the importance of nutrition and physical fitness, but only recently has obesity been a factor. State and local governments can focus on specific needs of their state, cities, and neighborhoods. Preventing childhood obesity will influence the design of streets and neighborhoods, plans for parks and community recreational centers, and the location of new schools and retail centers.

In 2006, the Federal Government began mandating that trans fat content be listed on nutritional labels. Government has taken a role eliminating trans fat:

• Tiburon, California is "America's first trans fat-free city.
• New York City passed a regulation banning trans fat in December 2006.
• In February 2007, Philadelphia copied New York City and banned trans fat in restaurants.
• In 2008, the California Legislature passed a statewide partial ban on trans fat which the Governor signed. It takes effect in effect in 2010 and 2011.

Other states and local governments are considering bans on the use of trans fat in restaurants.

Trans Fat

The National Academy of Sciences (NAS) advises the United States and Canadian governments on nutritional science for use in Public policy and product labeling programs. The dietary reference intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids contains their findings and recommendations regarding consumption of trans fat.³¹

Their recommendations are based on two key facts. First, "trans fatty acids are not essential and provide no known benefit to human health", whether of animal or plant origin. Second, while both saturated and trans fats increase levels of LDL cholesterol, trans fats also lower levels of HDL cholesterol thus increasing the risk of coronary heart disease (CHD). The NAS is concerned "that dietary trans fatty acids are more deleterious with respect to CHD than saturated fatty acids". This analysis is supported by a 2006 New England Journal of Medicine (NEJM) scientific review that states "from a nutritional standpoint, the consumption of trans fatty acids results in considerable potential harm but no apparent benefit."³²

Because of these facts and concerns, the NAS has concluded there is no safe level of trans fat consumption. There is no adequate level, recommended daily amount or tolerable upper limit for trans fats. This is because any incremental increase in trans fat intake increases the risk of coronary heart disease.

Despite this concern, the NAS dietary recommendations have not recommended the elimination of trans fat from the diet. This is because trans fat is naturally present in many animal foods in trace quantities, and therefore its removal from ordinary diets might introduce undesirable side effects and nutritional imbalances if proper nutritional planning is not undertaken. The NAS has therefore "recommended that trans fatty acid consumption be as low as possible while consuming a nutritionally adequate diet.

Obesity research indicates that trans fat may increase weight gain and abdominal fat, despite a similar caloric intake. A 6-year experiment revealed that monkeys fed a trans-fat diet gained 7.2% of their body weight, as compared to 1.8% for monkeys on a mono-unsaturated fat diet. Although obesity is frequently linked to trans fat in the popular media, this is generally in the context of eating too many calories; there is no scientific consensus connecting trans fat and obesity.³³

Food Industry

The National Academy of Sciences sponsored a meeting with representatives of big food companies that market to children to discuss issues related to obesity and advertising. It has been the assertion of some health care advocates that increased food advertising to children under 12 is related to the growing level of obesity in children in the United States.³⁴

The Dietary Guidelines for Americans 2010 reports that the proportion of daily calorie intake from foods eaten away from home has increased, and evidence shows that children, adolescents, and adults who eat out, particularly at fast food restaurants, are at increased risk of weight gain, overweight, and obesity. The strongest association between fast food consumption and obesity is when one or more fast food meals are consumed per week. As a result of the changing food environment, individuals need to deliberately make food choices, both at home and away from home, that are nutrient dense, low in calories, and appropriate in portion size.³⁵

As a result of consumer group lawsuits against food manufactures and retail chains, there has been an industry wide effort to reduce trans fat from its products:

• Kraft eliminated trans fat from Oreos and reduced or eliminated it in about 650 other products.
• McDonald's agreed to inform its customers that it had not changed to the lower trans fat cooking oil by placing prominent notices in all of its restaurants nationwide and in the media. It also agreed to pay $7 million to the American Heart Association for a trans fat program
• Wendy's is the first among all fast food chains to drop trans fat
• The Girl Scouts of America announced in November 2006 that all of their cookies will contain 0.5g trans fats per serving, thus meeting or exceeding the FDA guidelines. However, trans fats from girl scout cookies can exceed recommended levels if more than one serving is consumed.
• America's largest grocer, Walmart, recently announced that it will reformulate its "Great Value" store brand line of food products to include less sodium and sugar, and the removal of all remaining industrially-produced trans fats. By 2015, Walmart intends to cut the sodium content of its Great Value products by 25 percent and the added sugar content by 10 percent. It will also cut all trans fats, including hydrogenated and partially-hydrogenated fats and oils, from its packaged food products.

Schools

Outside of the home children and adolescents spend the majority of their time in school. Schools should teach children about good nutrition, physical activity and their influence on health. These concepts must not only be taught but put into practice.

The CDC reports that vending machines and snack bars are in 98% of high schools, 74% of junior and middle schools, and 43% of elementary schools. With the assumption that the average teen drinks 2 sodas a day- that's 300 extra calories. At that rate a child could gain as much as 2.5 pounds a month. Instead of urging children to drink water and low-fat milk, schools are exposing children to high calorie soft drinks. In an effort to remove soda some schools have replaced soft drinks with sport drinks and juices. In New York carbonated drinks have been replaced with 100% juice versions of Snapple, which actually has more calories and grams of sugar than regular soda.³⁶

One way state legislators and school districts have begun to deal with the obesity epidemic in youth is by taking soda machines out of public schools. But many schools have become dependent on the revenue from their exclusive contracts with soft drink companies. The money goes to help pay for programs that would otherwise be unavailable to many kids.

The obesity program at Children's Hospital-Boston reports that soft drinks are a particular concern because consumption rates have increased so dramatically in the last three decades. In the 1950s, children drank three cups of milk for every cup of soft drink. And today that ratio is reversed - three cups of soft drinks for every cup of milk. Observational studies- have suggested that soft drink consumption promotes obesity in a very dramatic fashion.

The Institute of Medicine has suggested that schools make sure that all foods available are consistent with federal nutrition guidelines, including food and beverages sold in vending machines. They suggest students have at least 30 minutes a day of physical exercise through gym class or recess. Schools can assist in providing BMI, weight, and height information to parents and to children.

Parents

Parents are the most important role models for children and influence their children by advancing certain values and attitudes and by rewarding specific behaviors. Teaching healthy behavior at a young age is important since change becomes more difficult with age. Parents are the household policy makers and make daily decisions on food and recreational activities.

A survey conducted by the American Obesity Association showed that:

• Almost 30% of parents said they were "somewhat" or "very" concerned about their children's weight
• 12 % of parents considered their children overweight
• Comparing their own childhood health habits to their children's, 27% of parents said their children eat less nutritiously, and 24% said their children are less physically active

The American Obesity Association also recommended that parents create a healthy eating and active environment:

• Limit the amount of TV watching
• Plan special active family-outings such as a hiking trip
• Assign active chores to every family member such as vacuuming, washing the car, or mowing the lawn
• Instill an interest in your child to try a new sport by joining a team at school or in the community.
• Make time for the entire family to engage in regular physical activity such as walking, bicycling, or rollerblading
• Implement the same healthy diet (rich in fruits, vegetables and grains) for the entire family, not just select individuals
• Plan times to prepare food together and eat meals together regularly
• Avoid other activities during mealtime such as TV watching
• Avoid serving portions that are too large
• Avoid forcing the child to eat if he/she is not hungry
• Limit the frequency of fast food eating to once a week.
• Avoid using food as a reward or lack of food as a punishment

Adolescent Bariatric Surgery

In April 2007 The National Institutes of Health (NIH) launched an observational study to evaluate the benefits and risks of bariatric surgery in adolescents. Bariatric surgery restricts stomach size and can decrease the amount of calories and nutrients the body absorbs. The Teen Longitudinal Assessment of Bariatric Surgery (LABS) study will help to determine if it is an appropriate treatment option for extremely overweight teens.³⁸

"The reasons for weight gain are complex and multifactorial, influenced by genetics, environment, eating and physical activity habits, and society. The information gathered from Teen-LABS will help determine if adolescence is the best time to intervene with this surgical therapy," says Thomas Inge, M.D., Ph.D., chair, Teen-LABS and principal investigator for the center at Cincinnati Children's Hospital Medical Center.

Ideally, the goal for overweight adolescents and teens is to slow the rate of weight gain by eating fewer calories and being more physically active. However, these changes are tough to achieve and other approaches, such as drug therapy, are only approved for use in children 16 years and older.

Although bariatric surgery among adolescents has increased, it is by no means a common procedure, representing fewer than one percent of the bariatric procedures performed nationwide. A study by the University of Medicine and Dentistry of New Jersey- Robert Wood Johnson Medical School and Cincinnati Children's Hospital Medical Center found that although the majority of surgery recipients are female, more male adolescents are requesting it. When researchers compared early post-operative results in teens and adults, they found that teens appear to handle the surgery better than adults. The study found that adolescents, ages 12 to 19, had shorter hospital stays and no in-hospital deaths, whereas a 0.2 percent mortality rate was recorded for adults.³⁸

For teens who have tried all other options, not only can the surgery help them reduce their health risks, but it is possible that risks of the surgery itself are lower for teens because obesity has had fewer decades to damage vital organ systems in the body. However, there are some concerns about the long-term effects of this type of operation on adolescents' developing bodies and minds.

Bariatric surgery should only be considered when:

• Adolescents have tried for six months to lose weight and have not been successful. Candidates should be severely overweight (BMI of 40 or more)
• Have reached their adult height usually 13 or older for girls, 15 or older for boys)
• Have serious weight-related health problems such as type 2 diabetes or heart disease
• Parents and patients are evaluated to see how emotionally prepared they are for the operation and the lifestyle changes they will need to make

The study also compared the costs of surgery for adults and teens, finding that adolescents had lower hospital charges. Total hospital charges in 2006 for adolescents undergoing bariatric surgery were $23.6 million and for adults was $3.8 billion. The average hospital charges associated with these procedures were 15 percent lower for adolescents than for adults.

Healthcare Professionals

Healthcare professionals have a vital role in preventing childhood obesity. As advisors both to children and families, they are uniquely positioned to monitor a child's weight status. This should be done with the parents (and child as age appropriate) and recommendations on dietary intake and physical activity can be made.

Healthcare professionals should routinely track BMI, offer counseling and guidance, and serve as role models. They need to make sure that people have accurate, science-based information about the factors that contribute to overweight and obesity. They are in a position to establish programs on obesity prevention and provide leadership in their own communities.

Academy of Nutrition and Dietetics Childhood Obesity Initiative

Kids Eat Right is the first joint initiative of the Academy of Nutrition and Dietetics (AND) and the AND Foundation (ANDF). It is a member-driven campaign dedicated to supporting the efforts of the White House and the First Lady to end the childhood obesity epidemic within a generation and AND's Childhood Obesity Prevention action plan. Kids Eat Right mobilizes AND members and their expertise to participate in community and school childhood obesity prevention efforts, as well as educating families, communities, and policy makers about the importance of quality nutrition. The goals of Kids Eat Right are:

• AND members take actions to support the White House Task Force on Childhood Obesity Prevention and AND's action plan recommendations to improve nutrition and physical activity in communities, schools and with families.
• Childhood obesity prevention and health promotion efforts address the total nutrient requirements of all youth.
• Registered dietitians are sought after and provide evidence-based nutrition guidance supporting quality nutrition and healthy weights.

The AND and ANDF have had programming, positions, and policies on weight management and total nutrient needs of adults and children for many years. AND recently developed a comprehensive Childhood Obesity Prevention action plan that is a driving factor for the creation of Kids Eat Right. With our action plan in place and the White House and First Lady's launch of the Let's Move! campaign, the AND and AND Foundation felt the time was right to mobilize its 71,000 members to support childhood obesity prevention with a population-based prevention approach. As the largest organization of registered dietitians and nutrition professionals, the AND sees that there is an opportunity and a responsibility to provide greater leadership and input into the national nutrition agenda and supporting local communities, schools, and families through a total nutrition approach to childhood obesity prevention.

Additionally, it is vital that AND members are viewed as key players in the childhood obesity prevention and health promotion area. In order to accomplish this, the AND recommends that its members need to engage in voluntary actions and make their presence known in childhood obesity prevention efforts.

Section VII. Children's Nutritional Needs & Dietary Plan

Eating a Wide Variety of Foods

Children's basic nutrition needs are very similar to those of other family members, although amounts of food needed differ because of age. The things that should be done for children are the same types of things that individuals should be doing for themselves. Offer children a variety of foods from the basic food groups:

• Breads, cereals, rice and pasta
• Vegetables
• Fruits
• Milk, yogurt and cheese
• Meats, poultry, fish, dry beans and peas, eggs, and nuts

It is important to offer a variety of foods within each food group. For example, in the fruit group, it is better to eat an orange, a half a grapefruit, and a kiwi over a three-day period rather than eating three oranges. Over time, young children will take in adequate nutrients when offered a wide variety of healthy foods.

Dietary Guidelines for Americans 2010 Report

Individuals and families make choices every day about what they will eat and drink and how physically active they will be. Today, Americans must make these choices within the context of an environment that promotes overconsumption of calories and discourages physical activity. This environment and the individual choices made within it have contributed to dramatic increases in the rates of overweight and obesity. Poor health outcomes, such as cardio-vascular disease, type 2 diabetes, and some types of cancer also have increased in tandem. To reverse these trends, a coordinated system-wide approach is needed-an approach that engages all sectors of society, including individuals and families, educators, communities and organizations, health professionals, small and large businesses, and policymakers.

Everyone has a role in the movement to make America healthy. By working together through policies, pro-grams, and partnerships, we can improve the health of the current generation and take responsibility for giving future generations a better chance to lead healthy and productive lives.⁴⁰

One way to think about how our current food and physical activity environment evolved, and about how it can be improved, is the Social-Ecological Model. Many public health experts agree that the Social-Ecological Model provides a framework to illustrate how all elements of society combine to shape an individual's food and physical activity choices, and ultimately one's calorie balance and chronic disease risk. The following describes some of the factors and influencers found within each element of the model: ⁴¹

Individual factors. Factors such as age, gender, income, race/ethnicity, genetics, and the presence of a disability can all influence an individual's and/or family's food intake and physical activity patterns. In order to change one's knowledge, attitude, beliefs, and behaviors, these individual factors should be considered and addressed (as possible).

Environmental settings. People regularly make decisions about food and physical activity in a variety of community settings such as schools, workplaces, faith-based organizations, recreational facilities, and foodservice and food retail establishments. These settings play an integral role in affecting individuals' and families' food and physical activity choices through their organizational environments and policies, and by providing health information to consumers.

Sectors of influence. Communities are influenced by a variety of sectors such as government, public health and health care systems, agriculture, industry, and media. Many of these sectors are important in determining the degree to which all individuals and families have access to healthy food and opportunities to be physically active in their own communities. Others have a strong influence on social norms and values.

Social and cultural norms and values. Social norms are guidelines that govern our thoughts, beliefs, and behaviors. These shared assumptions of appropriate behavior are based on the values of a society and are reflected in everything from laws to personal expectations. With regard to nutrition and physical activity, cultural norms could include types of foods and beverages consumed, when and how foods and beverages are consumed, accept-able ranges of body weight, and how much physical activity is incorporated into one's free time. Making healthy choices can be more difficult if those healthy choices are not strongly valued within a society.

The Social-Ecological Model illustrates the roles that various segments of society can play in making healthy choices more widely accessible and desirable. The model considers the interactions between individuals and families, environmental settings and various sectors of influence, as well as the impact of social and cultural norms and values.

The framework promotes movement toward a society oriented to chronic disease prevention. Efforts to improve dietary intake and increase physical activity are more likely to be successful when using this type of coordinated system-wide approach.

2010 Dietary Guidelines

Ultimately, Americans make their own food and physical activity choices at the individual (and family) level. In order for Americans to make healthy choices, however, they need to have opportunities to purchase and consume healthy foods and engage in physical activity. Although individual behavior change is critical, a truly effective and sustainable improvement in the Nation's health will require a multi-sector approach that applies the Social-Ecological Model to improve the food and physical activity environment.

This type of approach emphasizes the development of coordinated partnerships, programs, and policies to support healthy eating and active living. Interventions should extend well beyond providing traditional education to individuals and families about healthy choices, and should help build skills, reshape the environment, and re-establish social norms to facilitate individuals' healthy choices.

The 2010 Dietary Guidelines' Call to Action includes three guiding principles:

1. Ensure that all Americans have access to nutritious foods and opportunities for physical activity.
2. Facilitate individual behavior change through environmental strategies.
3. Set the stage for lifelong healthy eating, physical activity, and weight management behaviors.

Individual communities and organizations, and those with expertise in assessing community and public health needs, should determine the most relevant and essential action steps needed for their particular community, organization, or population.

Disparities in health among racial and ethnic minorities, individuals with disabilities, and different socioeconomic groups are of substantial concern. Research has demonstrated that some Americans lack access to affordable nutritious foods and/or opportunities for safe physical activity in their neighborhoods. This lack of access makes it a challenge for many Americans to consume a diet consistent with the Dietary Guidelines for Americans, 2010 and maintain physical activity levels consistent with the 2008 Physical Activity Guidelines for Americans. Thus, access may be related to overall disparities in health. In order for individuals and families to be able to make healthy lifestyle choices, they first need to be aware of and have access to those healthy choices. Access includes not only availability of these choices, but also affordability and safety. Acceptability of the choices is also important.

The following strategies can be used to help ensure that all Americans have access to nutritious foods and opportunities for physical activity:

• Create local-, State-, and national-level strategic plans to achieve Dietary Guidelines and Physical Activity Guidelines recommendations among individuals, families, and communities.
• Recognize health disparities among subpopulations and ensure equitable access to safe and affordable healthy foods and opportunities for physical activity for all people.
• Expand access to grocery stores, farmers markets, and other outlets for healthy foods.
• Develop and expand safe, effective, and sustainable agriculture and aquaculture practices to ensure availability of recommended amounts of healthy foods to all segments of the population.
• Increase food security among at-risk populations by promoting nutrition assistance programs.
• Facilitate attainment of the nutrition, food safety, and physical activity objectives outlined in Healthy People 2020.

Facilitate Individual Behavior Change Through Environmental Strategies

In addition to limited access, many people lack the information or motivation needed to achieve and maintain healthy nutrition and physical activity behaviors. Although more consumer education is needed on achieving calorie balance, meeting nutrient needs, and staying physically active, information alone does not lead to behavior change. People need to value the outcomes associated with the change and need to believe that the changes can fit into their lifestyles. An environment that supports and facilitates healthy behavior changes, with cultural sensitivity, should be in place for this to occur.

The following strategies can be used to address these issues and support individual behavior change:

• Empower individuals and families with improved nutrition literacy, gardening, and cooking skills to heighten enjoyment of preparing and consuming healthy foods.
• Initiate partnerships with food producers, sup-pliers, and retailers to promote the development and availability of appropriate portions of afford-able, nutritious food products (including, but not limited to, those lower in sodium, solid fats, and added sugars) in food retail and foodservice establishments.
• Develop legislation, policies, and systems in key sec-tors such as public health, health care, retail, school foodservice, recreation/fitness, transportation, and nonprofit/volunteer to prevent and reduce obesity.
• Support future research that will further examine the individual, community, and system factors that contribute to the adoption of healthy eating and physical activity behaviors; identify best practices and facilitate adoption of those practices.
• Implement the U.S. National Physical Activity Plan to increase physical activity and reduce sedentary behavior.

Lifelong Healthy Eating, Physical Activity, and Weight Management Behaviors

Primary prevention of obesity and related risk factors is the single most powerful public health approach to reversing America's obesity epidemic over the long term. Lifelong habits are developed throughout childhood, and every opportunity should be provided to build healthy habits at the earliest stages of life. This process begins in utero. The development of standardized approaches to pro-mote healthy pre-pregnancy weight, appropriate weight gain during pregnancy, the initiation and maintenance of breastfeeding during infancy, and a return to healthy weight status postpartum can help prevent overweight and obesity throughout the life span.

Parents and caregivers serve as important role models for children and are responsible for provid-ing them with nutritious foods and opportunities for physical activity. Outside influencers (e.g., policy-makers, educators, health professionals) should build upon existing systems and infrastructures to support parents, caregivers, schools, and communities in facilitating positive eating and physical activity choices throughout life. The following strategies can be used to help create and promote healthy lifestyles for children:

• Ensure that all meals and snacks sold and served in schools and childcare and early childhood settings are consistent with the Dietary Guidelines.
• Provide comprehensive health, nutrition, and physical education programs in educational settings, and place special emphasis on food preparation skills, food safety, and lifelong physical activity.
• Identify approaches for assessing and tracking children's body mass index (or other valid measures) for use by health professionals to identify overweight and obesity and implement appropriate interventions.
• Encourage physical activity in schools, childcare, and early childhood settings through physical education programs, recess, and support for active transportation initiatives (e.g., walk-to-school programs).
• Reduce children's screen (television and computer) time.
• Develop and support effective policies to limit food and beverage marketing to children.
• Support children's programs that promote healthy nutrition and physical activity throughout the year, including summer.

The ultimate goal of the Dietary Guidelines for Americans is to improve the health of our Nation's current and future generations by facilitating and promoting healthy eating and physical activity choices so that these behaviors become the norm among all individuals. Meeting this goal will require comprehensive and coordinated system-wide approaches across our Nation- approaches that engage every level of society and reshape the environment so that the healthy choices are the easy, accessible, and desirable choices for all.

Child's Nutritional Needs

Children move though growth spurts throughout childhood. Usually a child will grow about 2 1/2 inches and gain about four or five pounds each year between the ages of 2 and 5. By 15 months old, most children have developed enough fine motor skills to feed themselves without help, if allowed to do so. Appetites vary with young children as well as adults. Parents and caregivers need to help promote a healthy pattern of eating rather than using controlling techniques such as restricting food intake of heavier children or pressuring smaller children to eat more. Attitudes and habits formed during the early childhood years can help establish lifelong health habits.⁴³

Different nutrients are needed for different functions in the body.

• Protein is needed for growth. Most of the protein in the diet is supplied by milk, meat, fish, poultry, eggs, cheese and dry beans and peas.
• Calcium is needed for strong bones and teeth. Dietary calcium is primarily found in milk and milk products such as cheese and yogurt and to a lesser extent in leafy green vegetables.
• Iron is an important mineral that comes from meat, poultry, fish, eggs, green leafy vegetables and iron-fortified breads and cereals. Iron from cereal will be absorbed better when served with a food rich in vitamin C.
• Citrus fruits and their juices and dark green or yellow vegetables are good sources of vitamin C and vitamin A, respectively.
• Water is needed to regulate body functions in young children. As a percentage of body weight, children have more water in their bodies than adults. Children can become dehydrated more quickly than adults. Offer water to your young child several times during the day.
• Fat is a necessary nutrient in a child's diet. It helps to provide extra calories and needed nutrients for active and growing children. No fat restriction should be applied to children below the age of 2 because their fast growth requires a high percentage of calories from fat. The following pattern is recommended by the American Heart Association for children over the age of 2:
• Saturated fatty acids - less than 10 percent of total calories; total fat - an average of no more than 30 percent of total calories;
• Dietary cholesterol - less than 300 milligrams per day. Each of these numbers refers to an average of nutrient intake over several days. It can help children (2 and older) to develop beneficial low-fat dietary habits by offering items such as reduced fat milk, non-fat yogurt and lean meats.

Sugary foods provide few nutrients and should be limited. Chewy, sticky, sugary foods may promote tooth decay if left on the teeth. Children should be taught to properly brush their teeth daily to help reduce tooth decay.

US Department of Health & Human Services developed the following family Dietary Guidelines for Healthy Eating:

• Guide the family's choices rather than dictate foods.
• Encourage children to eat when hungry and to eat slowly.
• Eat meals together as a family as often as possible.
• Carefully cut down on the amount of fat and calories in the family's diet.
• Don't place the child on a restrictive diet.
• Avoid the use of food as a reward.
• Avoid withholding food as punishment.
• Children should be encouraged to drink water and to limit intake of beverages with added sugars, such as soft drinks, fruit juice drinks, and sports drinks.
• Plan for healthy snacks.
• Stock the refrigerator with fat-free or low-fat milk, fresh fruit, and vegetables instead of soft drinks or snacks that are high in fat, calories, or added sugars and low in essential nutrients.
• Aim to eat at least 5 servings of fruits and vegetables each day.
• Discourage eating meals or snacks while watching TV.
• Eating a healthy breakfast is a good way to start the day and may be important in achieving and maintaining a healthy weight.

Developing a Child's Weight Loss Plan

There are many ways to create a healthy eating pattern, but they all start with the three food groups: grains, fruits, and vegetables. Eating a variety of grains (especially whole grain foods), fruits, and vegetables is the basis of healthy eating. Enjoy meals that have rice, pasta, tortillas, or whole grain bread at the center of the plate, accompanied by plenty of fruits and vegetables and a moderate amount of low-fat foods from the milk group and the meat and beans group. Limit the foods high in fat or sugars.⁴⁴

According to the US Department of Health & Human Services the daily numbers of servings children need for each food group are:

The University of Nebraska Cooperative Extension developed the following guide for the nutritional needs and healthy eating patterns of children ages 2 to 5:

US Department of Health & Human Services recommends that if the child is overweight that the weight loss plan should consider the variables:⁴⁵

• Many overweight children who are still growing will not need to lose weight, but can reduce their rate of weight gain so that they can "grow into" their weight.
• The child's diet should be safe and nutritious. It should include all of the Recommended Dietary Allowances (RDAs) for vitamins, minerals, and protein and contain the foods from the major Food Guide Pyramid groups. Any weight-loss diet should be low in calories (energy) only, not in essential nutrients.
• Even with extremely overweight children, weight loss should be gradual.
• Crash diets and diet pills can compromise growth and are not recommended by many healthcare professionals.
• Weight lost during a diet is frequently regained unless children are motivated to change their eating habits and activity levels for a lifetime.
• Weight control must be considered a lifelong effort.
• Any weight management program for children should be supervised by a physician.

Weight Loss

For overweight children and adolescents, the goal is to slow the rate of weight gain while achieving normal growth and development.⁴⁶

The Dietary Guidelines for Americans 2010 key recommendations for specific population groups regarding weight loss are:⁴⁷

• Those who need to lose weight. Aim for a slow, steady weight loss by decreasing calorie intake while maintaining an adequate nutrient intake and increasing physical activity.
• Overweight children. Reduce the rate of weight gain while allowing growth and development. Consult a healthcare provider before placing a child on a weight reduction diet.
• Pregnant women. Ensure appropriate weight gain as specified by a healthcare provider.
• Breastfeeding women. Moderate weight reduction is safe and does not compromise weight gain of the nursing infant.
• Overweight adults and overweight children with chronic diseases and/or on medication. Consult a healthcare provider about weight loss strategies prior to starting a weight-reduction program to ensure appropriate management of other health conditions.

When developing a child's dietary plans the US Department of Health & Human Services has the following general suggestions for the family to use:⁴⁸

• Let the child know he or she is loved and appreciated whatever his or her weight. An overweight child probably knows better than anyone else that he or she has a weight problem. Overweight children need support, acceptance, and encouragement from their parents.
• Focus on the child's health and positive qualities, not the child's weight.
• Try not to make the child feel different if he or she is overweight but focus on gradually changing the family's physical activity and eating habits.
• Parents should be a good role model for their child. If the child sees his or her parents enjoying healthy foods and physical activity, he or she is more likely to do the same now and for the rest of his or her life.
• Realize that an appropriate goal for many overweight children is to maintain their current weight while growing normally in height.

Compare the recommended number of servings and the serving sizes with what is usually eaten. If they don't need many calories (because they are inactive, for example), aim for the lower number of servings. Notice that some of the serving sizes are smaller than what one might usually eat or see on food labels. For example, many people eat 2 slices of bread in a meal, which equal 2 servings. So it's easy to meet the recommended number of servings. Except for milk young children 2 to 3 years old need the same number of servings as others, but smaller serving sizes.

Also, notice that many of the meals and snacks that are eaten contain items from several food groups. For example, a sandwich may provide bread from the grains group, turkey from the meat and beans group, and cheese from the milk group.

Choose a variety of foods for good nutrition. Since foods within most food groups differ in their nutritional content and other beneficial substances, choosing a variety helps one get all the nutrients and fiber that children and adolescents need. It can also help keep the meals interesting from day to day.

Healthful Eating Patterns

Different people like different foods and like to prepare the same foods in different ways. Culture, family background, religion, moral beliefs, the cost and availability of food, life experiences, food intolerances, and allergies affect people's food choices. It is recommended that the Food Guide Pyramid be used as a starting point to shape the person's eating pattern. It provides a good guide to make sure individuals get enough nutrients. They should make choices from each major group in the Food Guide Pyramid, and combine them however they like. For example, those who like Mexican cuisine might choose tortillas from the grains group and beans from the meat and beans group, while those who eat Asian food might choose rice from the grains group and tofu from the meat and beans group.

If an individual usually avoids all foods from one or two of the food groups, they should make sure to get enough nutrients from other food groups. For example, if individuals choose not to eat milk products because of intolerance to lactose or for other reasons, they should choose other foods that are good sources of calcium, and they should be sure to get enough vitamin D. Meat, fish, and poultry are major contributors of iron, zinc, and B vitamins in most American diets. If they choose to avoid all or most animal products, it is recommend that they be sure to get enough iron, vitamin B12, calcium, and zinc from other sources. Vegetarian diets can be consistent with the Dietary Guidelines for Americans and meet Recommended Dietary Allowances for nutrients.

The Dietary Guidelines for Americans 2010 recommends that a healthy eating pattern should include the following:

• Balance the food one eats with physical activity
• Choose a diet with plenty of grain products, vegetables, and fruits.
• Choose a diet low in fat, saturated fat, and cholesterol
• Choose a diet moderate in sugars
• Choose a diet moderate in salt and sodium
• Support programs that encourage children to choose a drug-free and alcohol-free lifestyle

Calcium

Calcium is an especially important nutrient for growing girls. Calcium is what makes bones and teeth strong, and 99 percent of the body's calcium content are found in bones and teeth make up. Adolescents and adults over age 50 have an especially high need for calcium, but most people need to eat plenty of good sources of calcium for healthy bones throughout life. When selecting dairy products to get enough calcium, choose those that are low in fat or fat-free to avoid getting too much saturated fat.

Experts advise adolescents, especially girls, to consume 1,300 mg of calcium every day to develop strong bones that support full growth. The food label helps the person know how much one serving of food contributes to the total amount of calcium that a person needs in a day-1,300 mg of calcium equals 130 percent of the Daily Value. A glass of milk furnishes 30 percent of the daily value for calcium, and a cup of yogurt is another 30 percent. Together they contribute 60 percent of the 130 percent daily goal for calcium. To get enough calcium, choose a variety of low-fat milk products, dark green leafy vegetables, and calcium-fortified juices and grains.⁴⁹

Getting enough calcium now will reduce the risk of broken, brittle bones when they are older. Women can begin losing bone mass at the age of 35. When we lose a lot of bone, this condition is called osteoporosis. Osteoporosis causes bones to become brittle and break with very little stress. To make sure that this does not happen, individuals need to make sure to get enough calcium now to so that their bones are strong throughout their lifetime.

Fat

The Dietary Guidelines for Americans 2010 lists the following key recommendations Children and Adolescents are:

• For children 2 to 3 years of age, keep total fat intake between 30 - 35% of calories
• For children and adolescents 4 to 18 years of age, between 25 - 35% of calories should be derived from mostly polyunsaturated and monounsaturated fat sources

Iron & Additional Nutrients

Young children, teenage girls, and women of childbearing age need enough good sources of iron, such as lean meats and cereals with added nutrients, to keep up their iron stores. Women who could become pregnant need extra folic acid, and older adults need extra vitamin D.

Potassium & Salt

The Dietary Guidelines for Americans 2010 recommends that another dietary measure to lower blood pressure is to consume a diet rich in potassium. A potassium-rich diet also blunts the effects of salt on blood pressure, may reduce the risk of developing kidney stones, and possibly decrease bone loss with age. The recommended intake of potassium is:

• Adolescents and adults 4,700 mg/day
• Children 1 to 3 years of age 3,000 mg/day
• 4 to 8 years of age 3,800 mg/day
• 9 to 13 years of age 4,500 mg/day

Potassium should come from food sources. Potassium-rich fruits and vegetables include leafy green vegetables, fruit from vines, and root vegetables. Although meat, milk, and cereal products contain potassium, the form of potassium in these foods is not as readily available for absorption.

The key recommendations for sodium and potassium usage are:

• Consume less than 2,300 mg (approximately 1 teaspoon of salt) of sodium per day.
• Choose and prepare foods with little salt. At the same time, consume potassium-rich foods, such as fruits and vegetables.

Most Americans of all ages need to increase their intake of potassium. To meet the recommended potassium intake levels, potassium-rich foods from the fruit, vegetable, and dairy groups must be selected. The recommendation is to eat foods high in heme-iron (e.g., meats) and/or consume iron-rich plant foods (e.g., spinach) or iron-fortified foods with an enhancer of iron.

Physical Activity

The Dietary Guidelines for Americans 2010 key recommendations for specific population groups are:⁵⁰

• Children and adolescents. Engage in at least 60 minutes of physical activity on most, preferably all, days of the week.
• Pregnant women. In the absence of medical or obstetric complications, incorporate 30 minutes or more of moderate intensity physical activity on most, if not all, days of the week. Avoid activities with a high risk of falling or abdominal trauma.
• Breastfeeding women. Be aware that regular exercise does not adversely affects the mother's ability to successfully breastfeed.
• Older adults. Participate in regular physical activity to reduce functional declines associated with aging and to achieve the other benefits of physical activity identified for all adults.

The excess intake of calories above the daily expenditure of energy leads to weight gain and can eventually lead to obesity. The main components of this equation are energy intake (diet) and energy expenditure (physical activity, metabolic rate, etc.). The nutrition and physical activity habits of U.S. children have been changing over the past 40 years. Research shows some correlation of these changes to the increases in obesity levels in children. The physical environment, socio-economic status and race/ethnicity, family structure, genetics, and advertising may also influence diet and levels of physical activity among American youth.

Available research shows that there are a number of root causes of obesity in children. Selecting one or two main causes or essential factors is next to impossible given the current data, because the potential influences of obesity are multiple and intertwined. There are large gaps in knowledge, limiting the ability to pinpoint a particular cause and determine the most effective ways to combat childhood obesity. Another research gap stems from lack of a prospective longitudinal study that links dietary and other behavior patterns to development of obesity. Another complication of current data is that there is a need for more precise and reliable measures of dietary intake and activity levels, as individual recall of events and diet are not the most dependable sources for information.

When thinking about early prevention of obesity, it is essential that more is understood about how genetics is involved and how the genes are triggered or react to environmental changes and stimuli. Additionally, research is only beginning to explain how taste preferences develop, their biochemical underpinnings and how this information may be useful in curbing childhood weight gain.

Primary prevention is not an option for many children who are already overweight. Research on successful interventions for children who are overweight or at risk of becoming overweight is extremely important to effectively reduce childhood obesity in this country. Overall, research has just begun to scratch the surface in elucidating the causes of obesity in children. Filling in the knowledge gaps will take time, as implementing some of the study designs that will best illuminate the complex interactions are time consuming and costly. However the fundamentals are, eat a balanced diet and devote adequate time to physical activity.

Section VIII. Bibliography of Additional Information Sources

Links to organizations found at this site are provided solely as a service. Links do not constitute an endorsement of these organizations or their programs by Vantage Professional Education (VPE), and none should be inferred. VPE is not responsible for the content of the individual organizations' web pages found at these links.

Section IX. Footnotes