Childhood obesity is a serious medical condition that affects children and adolescents. It occurs when a child is well above the normal weight for his or her age and height. Childhood obesity is particularly troubling because the extra pounds often start children on the path to health problems that were once confined to adults, such as diabetes, high blood pressure and high cholesterol.

Obesity in kids is now epidemic in the United States. The number of children who are overweight has doubled in the last two to three decades; currently one child in five is overweight. The increase is in both children and adolescents, and in all age, race and gender groups.

Although huge advances have been made over the past years in children's health and morality the obesity epidemic threatens to over-ride some of these advances. Significant health consequences attributed to overweight warrant that urgent preventative action must be taken. Changes in diet and exercise must be implemented from many directions and at multiple levels.

This course contains information from The Dietary Guidelines for Americans 2005 is revised every 5 years and incorporates the analysis of new scientific information by the Dietary Guidelines Advisory Committee (DGAC). The committee is appointed by the Secretaries of the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Agriculture (USDA).

Course Objectives

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

1. Discuss childhood obesity and overweight definitions
2. Describe the prevalence of childhood obesity
3. Identify the complications associated with childhood obesity
4. Identify the causes of childhood obesity
5. Discuss the management and treatment of childhood obesity
6. Identify the solutions for reducing childhood obesity
7. Identify children's nutritional needs and dietary plans

Section II. Childhood Obesity Prevalence

Obesity and Overweight Defined

The National Institutes of Health defines obesity and overweight using the Body Mass Index (BMI) which is a calculation of a person's weight in kilograms divided by the square of their height in meters. Children are considered overweight if they are at or above the 95th percentile in the gender and age specific "growth chart." However, BMI is not a reliable measure of fatness for children, especially across varying ages and degrees of maturity, when compared to adults who have attained their height.

The Centers for Disease Control (CDC) avoids using the word "obesity" for children and adolescents. Instead, they suggest 2 levels of overweight:

• 85th percentile as an "at risk level"
• 95th percentile, the more severe level

The American Obesity Association uses the 85th percentile of BMI as a reference point for overweight and the 95th percentile for obesity.

In this course the 95th percentile of BMI is used as criteria for obesity because:

• It is the criteria for more aggressive treatment.
• It corresponds to the BMI for obesity in adults
• It is a criteria in clinical trials of childhood obesity treatments
• It is linked to elevated blood pressure and lipids in older adolescents
• It is the role of the healthcare professional to determine whether an overweight child or adolescent's weight and growth patterns place him/her at risk.

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

Childhood Obesity Prevalence

The prevalence of overweight among children aged 6 to 11 more than doubled in the past 20 years, going from 7% in 1980 to 18.8% in 2004. The rate among adolescents aged 12 to 19 more than tripled, increasing from 5% to 17.1%.¹

Overweight Prevalence

Overweight is a serious health concern for children and adolescents. Data from two National Health and Nutrition Examination Survey (NHANES) surveys (1976-1980 and 2003-2004) show that the prevalence of overweight is increasing: for children aged 2-5 years, prevalence increased from 5.0% to 13.9%; for those aged 6-11 years, prevalence increased from 6.5% to 18.8%; and for those aged 12-19 years, prevalence increased from 5.0% to 17.4%.²

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 NHANES survey. The most recent NHANES data (2003-2004) showed that for children aged 6 -11 years and 12-19 years, the prevalence of overweight was 18.8% and 17.4% respectively. These prevalence figures are more than three times the target prevalence of 5% set in Healthy People 2010.

Childhood Overweight Overweight Youth, 2005 and 2003.

Percentage of high school students who were overweight* - selected U.S. states, Youth Risk Behavior Survey, 2005.3

* Students who were = 95th percentile for body mass index, by age and sex, on the basis of reference data.

Percentage of high school students who were overweight* - selected U.S. states, Youth Risk Behavior Survey, 2003.

* Students who were = 95th percentile for body mass index, by age and sex, on the basis of reference data.

Trends in Childhood Overweight

The following graphs show trends in childhood overweight based on NHANES data for various age groups, beginning with NHANES I (1971-1974) and ending with NHANES 2003-2004 (the most recently available published data).

Data from NHANES I (1971-1974) to NHANES 2003-2004 show increases in overweight among all age groups:

• Among preschool-aged children, aged 2-5 years, the prevalence of overweight increased from 5.0% to 13.9%
• Among school-aged children, aged 6-11 years, the prevalence of overweight increased from 4.0% to 18.8%
• Among school-aged adolescents, aged 12-19 years, the prevalence of overweight increased from 6.1% to 17.4%

Overweight Among Racial/Ethnic Groups

Although overweight has increased for all children and adolescents over time, NHANES data indicate disparities among racial/ethnic groups. The following graphs compare the prevalence for racial/ethnic groups of adolescent boys and girls aged 12 through 19 years.

Racial/Ethnic Comparison: Boys Aged 12-19 Years

The most recent NHANES data (2003 - 2004) showed that for boys, aged 12-19 years:

• The prevalence rate of overweight was slightly higher among adolescent non-Hispanic white boys (19.1%) than among non-Hispanic black boys (18.5%) and Mexican American boys (18.3%).

Data from NHANES III (1988 - 1994) through NHANES 2003-2004 showed that adolescent non-Hispanic white and black boys experienced larger increases in the prevalence of overweight (7.5% and 7.8% respectively) compared to the increase among Mexican American boys (4.2%).

• Among non-Hispanic white boys, the prevalence of overweight increased from 11.6% to 19.1%.
• Among non-Hispanic black boys, the prevalence of overweight increased from 10.7% to 18.5%.
• Among Mexican American boys, the prevalence of overweight increased from 14.1% to 18.3%.

Racial/Ethnic Comparison: Girls Aged 12-19 Years

The most recent NHANES data (2003 - 2004) showed that for girls, aged 12-19 years:

• Non-Hispanic black girls had the highest prevalence of overweight (25.4%) compared to that of non-Hispanic white (15.4%) and Mexican American (14.1%) girls.

Data from NHANES III (1988 - 1994) through NHANES 2003-2004 showed that non-Hispanic black adolescent girls experienced the largest increase in the prevalence of overweight (12.2%) compared to non-Hispanic white adolescent (8.0%) and Mexican American adolescent (4.9%) girls.

• Among non-Hispanic white girls, the prevalence of overweight increased from 7.4% to 15.4%
• Among non-Hispanic black girls, the prevalence of overweight increased from 13.2% to 25.4%
• Among Mexican American girls, the prevalence of overweight increased from 9.2% to 14.1%

Data representative of 9th through 12th grade students in public and private schools throughout the United States.

Section III. Complications of Childhood Obesity

Health Risks

The Mayo Clinic report that obese children can develop serious health problems, such as diabetes and heart disease, often carrying these conditions into an obese adulthood. Overweight children are at higher risk of developing:⁴

• Type 2 diabetes
• Metabolic syndrome
• High blood pressure
• Asthma and other respiratory problems
• Sleep disorders
• Liver disease
• Early puberty or menarche
• Eating disorders
• Skin infections

Diabetes

The National Institute of Health 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.

• 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

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.⁶

• 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 American Academy of Allergy, Asthma & Immunology reports that the debate over whether or not a direct link exists between asthma and obesity continues to be studied. While the results have been inconclusive to this point, it cannot be denied that both conditions are on the rise among children.⁷

Since some of the risk factors for asthma and obesity appear to be related, there have been a number of studies done to assess whether there is a genetic link between the two conditions. Several studies have shown a strong association between body mass index, and risk for developing asthma.

One study by a group of German researchers found a strong relationship between obesity and asthma, but no similar relationship between obesity and allergies. The researchers speculated that the connection between obesity and asthma, rather than being genetic, was physical. Specifically, they believed that the increased physical work done by the lungs of an overweight individual was the basis for the connection between the two conditions.

Early Onset Puberty

A Study by The University of Michigan found that increasing rates of childhood obesity may be responsible for a dramatic increase in early-onset puberty in girls, new research suggests.

Obese girls, defined as at least 10 kilograms (22 pounds) overweight, had an 80% chance of developing breasts before their ninth birthday and starting menstruation before age 12 - the western average for menstruation is about 12.7 years. Early-onset puberty could have serious health and social consequences, experts say, including increased incidence of teenage depression and of cancer in later life.⁸

The study followed 354 girls who were either normal weight, at risk of being overweight, or overweight from age 3 to age 12. They found a strong association between elevated body weights at all ages and the early onset of puberty as determined by breast development and the onset of menstruation.

While previous studies have noted a relationship between obesity in girls and early puberty, it remained unclear which condition caused the other. By tracking the girls from such an early age, the research showed that it is increased body fatness that cause the early onset of puberty and not the other way around. It is unsure why obesity is causing girls to mature faster but speculates that hormones released from the added fat cells could play a role.

Sleep Apnea

Sleep apnea is a serious, debilitating and potentially life-threatening sleep disorder. It is estimated that sleep apnea occurs in about 7% of overweight children according to the National Sleep Foundation (NSF).⁹

Sleep apnea is characterized by brief but numerous involuntary breathing pauses during sleep. These breathing pauses cause awakenings throughout the night, making it impossible for sleep apnea sufferers to enjoy a night of deep, restorative sleep. People with sleep apnea often feel sleepy during the day and their concentration and daytime performance suffer.

Sleep apnea, generally considered a problem among middle-aged men, can be a problem for youngsters, too. With the increasing rates of obesity in children, the Sleep Disorders Center at Children's Hospital in Philadelphia found there to be an increase in sleep apnea. There are patients as young as 5 with obesity caused sleep apnea. Obesity linked sleep apnea can cause death when the fat in the back of the throat combines with the large tonsils to block the airway.

The repercussions of sleep apnea and poor sleep for children are vast. When children do not get the sleep they need, they are at risk for health, performance and safety problems; difficulties in school are often the result. However, sleep deprivation in children is often overlooked or attributed to attention-deficit or behavior disorders.

Economic Costs

The U.S. Public Health Service in a March 2004 hearing 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.

Psychosocial Implications

Obese children face serious psychosocial burdens that can impair academic and social functioning and may continue into adulthood. Childhood obesity and overweight is linked to discrimination, poor self-esteem, and depression. Overweight and obese children feel they have a lower quality of life than their normal weight counterparts. In a recent study conducted by the Royal Children's Hospital in Parkville, Australia, children reported that physical, emotional and social well-being decreased as soon as a child's weight began to rise above average.

Children between the ages of 9 and 12 were asked to complete a survey about their physical, emotional, social and school issues. The survey included statements such as "It is hard for me to run" or "Other kids tease me," and were answered using a scale of 0-4, with 0 meaning never and 4 meaning almost always. As a child's weight increased, his or her survey score decreased, indicating a lower quality of life. The average score in the survey for non-overweight children was 80.5, 79.3 for overweight children, and 74 for obese children. Being overweight clearly had a diminishing effect on a child's quality of life.

Overweight children and adolescents report negative stereotyping made by normal weight counterparts. Males experience assumptions included being lazy and unclean, and suffer from teasing and bullying. Females have experienced intentional weight-related teasing, jokes and hurtful comments from strangers. Females who develop a negative body image are at a greater risk for the development of eating disorders.

Emotional and social factors are both a potential cause of obesity and a potential consequence. Behavioral problems have been shown to be associated with the development of obesity in a study of 8-11 year-olds over a 2 year period among children who were not obese at baseline. There is an association between adult obesity and traumatic childhood experiences (e.g. physical abuse, sexual abuse, or emotional neglect). Obesity and overweight can have an impact on a child's physical and emotional well-being and to their overall quality of life.¹¹

Section IV. Causes of Childhood Obesity

Understanding the Causes of Childhood Obesity

It appears straightforward -calories consumed versus calories expended. But, there are many factors that influence eating and physical activity. There are social, environmental and policy issues that interact to affect behavior. US society has changed dramatically during the time period the obesity epidemic has developed. These changes have affected the imbalance in the amount of calories that children consume and the amount that they expend. Although certain medical disorders can cause obesity, less than 1 percent of all obesity is caused by physical problems. Obesity in childhood and adolescence can be related to:

• Poor eating habits
• Overeating or binging
• Lack of exercise (i.e., couch potato kids)
• Family history of obesity
• Medical illnesses (endocrine, neurological problems)
• Medications (steroids, some psychiatric medications)
• Stressful life events or changes (separations, divorce, moves, deaths, abuse)
• Family and peer problems
• Low self-esteem
• Depression or other emotional problems

Contributing Factors

Many factors are involved in the development of childhood obesity with two of the strongest being genetics and the child's environment. A study by The University of Minnesota found that of 504 youth the degree of obesity in the family (parents and grandparents) and the degree of overweight in puberty were the most important factors for weight level in adulthood. The risk of obesity is greatest when both parents are obese. Parental obesity increases risk of obesity by 2- to 3-fold in both overweight and non-overweight children at all ages. Obesity in children under age 3 does not appear to predict future obesity, unless at least one parent is obese.¹²

The odds for obesity continuing into adulthood increase with the number of parents who are overweight. Twin studies and adoption studies are frequently used in determining the influence of genetics versus that of environmental factors on the development of obesity. These studies have shown that children with obese biological parents tended to become obese even if adoptive parents were slim. Studies have shown genetic influences on fat mass during childhood and adolescence may contribute 70% to individual differences in BMI.

However, genetics alone do not determine obesity. A child who is genetically inclined to become overweight will develop varying levels of when exposed to different environments. For instance, a child who is predisposed to obesity can be expected to become very overweight in an environment that limits physical activity and exposes the child to many high fat, high calorie foods. Conversely, if this same child is encouraged to be physically active and is offered a diet high in fruits, vegetables and whole grains, weight control may not be a problem. Thus, parental modeling and other environmental factors may determine the degree of adiposity (tendency to become obese) in youth who are genetically predisposed to obesity. Studies of parental factors on child weight show that these can have a profound effect on decreasing a child's ability to control food intake.

Although the role of resting metabolic rate (RMR) in the development of obesity remains controversial, there is accumulating evidence that obesity more likely develops in individuals with lower basal metabolic rates (BMR). Studies of Pima Indians have shown that low resting energy expenditure predicts the development of weight gain over a 2-year period.

Other studies involving infants have revealed higher weight gains with low-resting energy expenditure. Other factors that may lead to childhood obesity include maternal famine, low birth weight and fetal hyperglycemia. Despite the fact that there is only a very small likelihood that overweight in infancy will persist into adulthood, some studies suggest that overfeeding in infancy may permanently enhance fat storage Additionally, breastfeeding and duration of breastfeeding may protect against development of excess adiposity in early life.

In addition to eating patterns, children learn from their parents and others in their environment about physical activity. The belief that young children are always naturally active is no longer true. Children watch more television daily, physical education has been markedly reduced in schools, many neighborhoods lack safe areas for walking, household chores are assisted by labor saving machines, and automobile travel has almost exclusively replaced walking or biking. Surveillance of preschool children at play shows that only 11% of play is spent in vigorous activity, with most of the other time spent in sedentary activity. Studies have shown that children who watch the most television were more than 8 times more likely to become obese. Each factor contributes to the degree of childhood obesity.

The Family

American family life has changed which has affected what children eat, where they eat it, how much they eat, and the amount of energy they use up at school and various leisure activities. There has been a shift in the role of women in society with trends such as, delayed marriage, childbearing outside of marriage, higher divorce rates, single parenthood, and work patterns of parents. Married mothers are also increasingly more likely than they were in the past to remain in the work force throughout their child-bearing years. In 2002, only 7 percent of all U.S. households consisted of married couples with children in which only the husband worked.

Families try to minimize food costs and preparation time which has resulted in consumption of foods that are high in calories and fat. Consumers are interested in convenience, shelf stability, portability and greater accessibility of foods throughout the day. Portion sizes for children aged 2 and older increased for most food consumed both at home and away from home and as portion size of food in drink has steadily increased so has the rise in obesity.

Outside the Home

The Institute of Medicine's Committee on Prevention of Obesity in Children and Youth found that food eaten outside the home by children has risen to 32% of total calories and household income spent on food outside the home has risen to 47%. Increased time demands on working parents are reflected in decreased time in meal planning and preparation. There has been an increase in snacking which has led to a large proportion of total daily calorie intake being derived from energy-dense snacks. At the same time there has been a decline in breakfast consumption among adolescents while children of working mothers are more likely to skip meals.¹³

The fact that more meals are eaten in restaurants and fast food outlets is not only influenced by convenience and lack of time. The National Restaurant Association concluded that two thirds of Americans regarded visiting a restaurant with family or friends allowed them to socialize and was a better use of their leisure time than cooking at home and cleaning up afterwards.

Trends in Food Consumption

Children and adolescents are not meeting the minimum servings of five fruits and vegetables daily as recommended by the American Dietetic Association. The Institute of Medicine found that in the year 2000, five vegetables-iceberg lettuce, frozen potatoes, fresh potatoes, potato chips, and canned tomatoes- accounted for 48 percent of total vegetable servings, while only 6 fruits-orange juice, apples, fresh grapes, and watermelon - accounted for 50% of all fruit servings.

They found that over the past 20 years there has been a significant decrease in the total amount of vegetables consumed by children aged 6-11 years. Today, only 24% of girls and 23 % of boys consumed the number of Food Guide Pyramid recommended fruit servings.¹⁴

In the past 20 years soft drinks have replaced milk in many children's diets. Milk consumption decreased by 37% in adolescent boys and 30% in adolescent girls. Children aged 6-11 years consumed 4 times as much milk as any other beverage, and adolescents aged 12-19 years drank 1.5 times as much milk as any other beverage. Children now aged 6-11 consumed 1.5 times as much milk as soft drinks and adolescents consumed twice as much soft drinks as milk. Soft drink consumption nearly tripled among adolescent boys from 7 to 22 ounces per day. By 14 years of age, 32% of adolescent girls and 52% of adolescent boys consumed 3 or more 8 ounce servings of soda daily.

All age and gender groups of children have shown an increased level of snacking and derive a large proportion of their daily calories energy-dense snacks.

Sleep and Obesity

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.¹⁵

"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.

Starting when the babies were 6 months old, mothers were asked how long their children napped during the day and how long they slept at night. Moms were asked again when the children were 1 and 2 years old. They were asked about TV time when the children reached age 2.The researchers combined the sleep answers to find an average pattern for each child during the first two years of life. They found 586 of the children slept an average of 12 or more hours a day and 329 of the children slept less than that. Among the long sleepers, 7 percent were obese at age 3.

The short sleepers fared worse. Twelve percent of them became obese 3-year-olds. Adding TV to the picture, 17 percent of those who slept less than 12 hours a day and watched two or more hours of television a day were obese by the time they were 3.

The researchers took into account other risk factors for obesity, including TV viewing, and still found the children who slept fewer than 12 hours a day had a doubled risk of being obese at age 3 than the other children.

Sleep's impact on appetite hormones may explain the effect, Taveras said. In prior studies, sleep-deprived adults produced more ghrelin, a hormone that promotes hunger, and less leptin, a hormone that signals fullness.

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.

The families in the study lived in Massachusetts and had relatively high incomes and education levels, making it difficult to apply the findings to everyone, Taveras acknowledged. Sleep researchers who read the study said it adds to growing evidence of the link between poor sleep and obesity. Every additional hour per night a third-grader spends sleeping reduces the child's chances of being obese in sixth grade by 40 percent.

Lack of Physical Activity

One of the major factors contributing to today's obesity rates in children is simply the fact that they are less active than ever before. In schools, physical activity classes have been partially or completely cut to save money and to satisfy federal wishes to focus on mathematics and English literacy.

Only 10% of kids walk to school on a regular basis and only half are enrolled in some type of physical activity class. In the U.S., Illinois is the only state that actually requires daily physical education classes for all class levels. By the time students are in high school, a phys. ed. class may only be required in one of the four years. In 1991, 42% of high school students enrolled in daily physical education classes. This number has now dropped to roughly 25%.

• Less than 40% of children participate in any type of organized activity session outside of school hours, and 23% participate in absolutely no physical activity at all.
• One-quarter of all high school students watch four or more hours of television a day, and increased television watching has been linked to a more sedentary lifestyle and an increased prevalence of obesity.

It has been proven that a child watching 21 hours of television a week, which is now quite normal, can decrease their chance of becoming obese by one-third by simply reducing their television watching by the same amount.

The Centers for Disease Control and Prevention (CDC) conducted a survey of nationally representative students in grades 9-12 called the Youth Risk Behavioral Surveillance System (YRBSS). The report documented that more than half of the students are not engaging in recommended levels of moderate or vigorous physical activity and 10 % reported they were inactive. A further CDC study, the Youth Media Campaign Longitudinal Survey (YMCLS) revealed in a nationally representative survey of youths aged 9 to 13 years that 61.5 % of youth in this age group do not participate in any organized physical activity during their non-school hours and 22.6 % do not engage in any free time physical activity.

There has also been a substantial decline in children who walk to school. From 1977 to 2001 the percentage of total school trips made by children aged 5 -15 years went from 20.2% to 12.5%. An estimated 31% of children aged 5-15 years who lived within a mile of school walked or bicycled only once during the previous week.

Children spend a considerable amount of their leisure time in front of the television. The time spent with electronic media has grown considerably and has increased the time spent in sedentary pursuits which has led to reduced outside activities. In 1999, the average American child resided in a home with 3 televisions, 3 radios, 3 tape players, 2 VCRs, 1 video game player, 2 compact disk players, and one computer.

In 2003, nearly all children aged 0 to 6 lived in a home with a television and the average number of VCRs or DVDs was 2.3. During a typical day, 36 percent of children watch television for one hour or less, 31 percent of children watch television for one to three hours, 16 percent watch television for 3 to five hours, and 17 percent watch television for more than 5 hours.

Daily Television Viewing by Children

Latino Youth

A John Hopkins University study revealed that a siege of fast-food commercials on Spanish-language television channels in the United States may be helping drive an obesity epidemic among Latino youth. Two or three food commercials air every hour during prime-time on two top Spanish-language stations in the United States, they found, and a third of these were aimed specifically at children.¹⁶

"While we cannot blame overweight and obesity solely on TV commercials, there is solid evidence that children exposed to such messages tend to have unhealthy diets and to be overweight," Dr. Darcy Thompson, a pediatrician at Johns Hopkins University in Baltimore who led the study, said in a statement.

Latino children make up one-fifth of the U.S. child population and have the highest obesity and overweight rates. Government estimates show that 30 percent of all Hispanic or Latino children in the United States are overweight, compared to 25 percent of white children. And a federal survey found that 50 percent of Hispanic or Latino children have a television in their bedrooms, compared to 20 percent of white children.

Writing in The Journal of Pediatrics, Thompson and colleagues said they reviewed 60 hours of programs airing between 3 p.m. and 9 p.m. on Univision and Telemundo, the two largest Spanish-language channels in the United States. Nearly half of all food commercials featured fast food, and more than half of all drink commercials promoted soda and drinks with high sugar content, they said.

The American Academy of Pediatricians recommends that young children should be restricted to two hours a day or less of TV viewing and says children younger than 2 should not watch any TV.

Teenagers With Eating Disorders

The American Academy of Child & Adolescent Psychiatry states that overeating related to tension, poor nutritional habits and food fads are relatively common eating problems for youngsters. In addition, two psychiatric eating disorders, anorexia nervosa and bulimia, are on the increase among teenage girls and young women and often run in families. In the United States, as many as 10 in 100 young women suffer from an eating disorder. These two eating disorders also occur in boys, but less often.¹⁷

These disorders are characterized by a preoccupation with food and a distortion of body image. Unfortunately, many teenagers hide these serious and sometimes fatal disorders from their families and friends.

Symptoms and warning signs of anorexia nervosa and bulimia include the following:

• A teenager with anorexia nervosa is typically a perfectionist and a high achiever in school. At the same time, she suffers from low self-esteem, irrationally believing she is fat regardless of how thin she becomes. Desperately needing a feeling of mastery over her life, the teenager with anorexia nervosa experiences a sense of control only when she says "no" to the normal food demands of her body. In a relentless pursuit to be thin, the girl starves herself. This often reaches the point of serious damage to the body, and in a small number of cases may lead to death.
• The symptoms of bulimia are usually different from those of anorexia nervosa. The patient binges on huge quantities of high-caloric food and/or purges her body of dreaded calories by self-induced vomiting and often by using laxatives. These binges may alternate with severe diets, resulting in dramatic weight fluctuations. Teenagers may try to hide the signs of throwing up by running water while spending long periods of time in the bathroom. The purging of bulimia presents a serious threat to the patient's physical health, including dehydration, hormonal imbalance, the depletion of important minerals, and damage to vital organs.

With comprehensive treatment, most teenagers can be relieved of the symptoms or helped to control eating disorders. The child and adolescent psychiatrist is trained to evaluate, diagnose, and treat these psychiatric disorders. Treatment for eating disorders usually requires a team approach; including individual therapy, family therapy, working with a primary care physician, working with a dietitian, and medication. Many adolescents also suffer from other problems; including depression, anxiety, and substance abuse.

The Community

Many urban and suburban designs discourage walking and other physical activity. The location and layout of some communities necessitate driving for transportation. In these areas, streets are often without sidewalks, and shopping areas located away from residential areas, which discourage walking and biking. Labor saving devices in the home also have led to a decrease in physical activity. Opportunities for physical activity must be safe and accessible.

Section V. Assessment and Treatment

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.¹⁸

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

A 24-hour recall combined with a food frequency or food record can assist in collecting such data. Parental attitudes toward eating and parental food-related practices must also be assessed.

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.

Recommended Goals for Weight Management by Age and BMI

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.

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.¹⁹

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."²⁰

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". Like the NAS, the World Health Organization has tried to balance public health goals with a practical level of trans fat consumption, recommending in 2003 that trans fats be limited to less than 1% of overall energy intake.

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.²¹

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.²²

However representatives of such companies as General Mills cited statistics that showed obesity varied widely across the country even though the marketing to children was at an even level throughout the country. McDonalds, which is facing a lawsuit accusing the company of misleading young consumers about the healthiness of its products, highlighted some of its recent advertising depicting healthy behavior. Ronald McDonald was featured doing jumping jacks. PepsiCo is putting more of its advertising budget into promoting products in a "Smart Spot" program. The company's healthiest foods such as, Baked Lays chips, Quaker oatmeal, Tropicana juices and a new reduced-sugar Cap'n Crunch cereal will be marketed with a special logo.

Some major food chains have chosen to remove or reduce trans fats in their products. In some cases these changes have been voluntary. In other cases, however, food vendors have been targeted by legal action that has generated a lot of media attention. In May 2003, BanTransFats.com Inc., a U.S. non-profit corporation, filed a lawsuit against the food manufacturer Kraft Foods in an attempt to force Kraft to remove trans fats from the Oreo cookie. The lawsuit was withdrawn when Kraft agreed to work on ways to find a substitute for the trans fat in the Oreo.

In November 2006, Arby's announced[ that by May 2007, it would be eliminating trans fat from its french fries and reducing it in other products. Similarly, in 2006, the Center for Science in the Public Interest sued KFC over its use of trans fats in fried foods. concerning their class action complaint. KFC reviewed alternative oil options, saying "there are a number of factors to consider including maintaining KFC's unique taste and flavor of Colonel Sanders' Original Recipe". In October, 2006, KFC announced that it will replace the partially hydrogenated soybean oil it currently uses with a zero-trans-fat low linolenic soybean oil in all restaurants in the US by April 2007, although its biscuits will still contain trans-fats.[Despite the US-specific nature of the lawsuit, KFC is making changes outside of the US as well; in Canada, KFC's brand owner is switching to trans-fat free Canadian canola oil by early 2007.²³

Wendy's announced in June 2006 plans to eliminate trans-fats from 6,300 restaurants in the United States and Canada, starting in August 2006. In November 2006, Taco Bell made a similar announcement, pledging to remove Trans Fat from many of their menu items by switching to canola oil. By April 2007, fifteen Taco Bell menu items were completely free of Trans Fat. In January 2007, McDonald''s announced they will start phasing out the trans fat in their fries after years of testing and several delays. This can be partially attributed to New York's recent ban, with the company stating they would not be selling a unique oil just for New York customers but would implement a nationwide change.²⁴

In response to a May 2007 law suit from the Center for Science in the Public Interest, Burger King announced that its 7,100 US restaurants will begin the switch to zero trans-fat oil by the end of 2007.

The Walt Disney Company announced that they will begin getting rid of trans fats in meals at US theme parks by the end of 2007, and will stop the inclusion of trans fats in licensed or promotional products by 2008.²⁵

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.²⁶

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.²⁷

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.²⁸

The study took 100 high school children in Cambridge, Massachusetts, who were drinking soft drinks at least once a day and randomly assigned them either to a control group, who were told to just basically keep doing what they're doing in terms of soft drink consumption and other lifestyle patterns, and an intervention group. The intervention group received home deliveries of non-calorie-containing beverages - that would be water, flavored waters, non-sugar-sweetened teas, and diet drinks, if they wanted - with the idea that by making these non-caloric beverages convenient and accessible it would more effectively eliminate sugar-sweetened beverages from their diets. Sugar-sweetened beverages are highly advertised to kids and ubiquitously available.

The non-caloric beverages were provided to their homes for a six month period. It was found, first off, that simply by making alternative beverages convenient and accessible to children, that they will almost totally eliminate the sugar-containing varieties from their diets. So, basically, advertising works, that the things that children find convenient and accessible are, in fact, influencing their eating habits. But perhaps most dramatically the study found that among the overweight children those receiving this intervention to decrease sugar-sweetened beverages lost an extra pound per month compared to those in the control group.

The effects of decreasing soft drinks increased with how heavy a child was. So among the normal weight children there was no effect. What it suggested was that those children replaced the calories from soft drinks from other parts of their diet.

The study defined sugar-sweetened beverages as any product in which the major source of calories came from sugar. By way of comparison, a typical regular soft drink is about ten percent sugar. So that means that for 12-oz. servings they're about ten teaspoons of sugar being consumed. .The study suggests that sugar-sweetened beverages are playing a uniquely adverse role in promoting weight gain, especially in children.

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.²⁹

"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.

"We know that bariatric surgery is not an easy way out for teens to control weight. They will still need to eat less food and exercise more," says Mary Horlick, M.D., project scientist for Teen-LABS and director of the Pediatric Clinical Obesity Program of the Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the sponsor of Teen-LABS at NIH. "We hope to learn whether or not bariatric surgery is suitable for teens and if it will help them remain at a healthy weight over the long-term."

Over the next five years, researchers will enroll 200 adolescents who are scheduled for bariatric surgery and compare their data to 200 adults who had bariatric surgery after being obese since their teen years. The researchers will collect information on the pre-operative and two year post-operative status of the participants, including measures of body composition, body fat, cardiovascular risks, sleep apnea episodes, diabetes indicators, depressive symptoms, quality of life, eating habits, and nutritional status. The investigators will also store serum, plasma, urine and genetic samples for future studies.

Teen-LABS will not pay for the costs of bariatric surgery or patient care. Study participants must be able to support the cost of their surgery and related patient care through medical insurance or other means. Adolescents between 14 to 19 years are eligible for the study, but younger patients also could be considered if they meet current criteria.

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.³⁰

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.

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 2005 Report

The Dietary Guidelines for Americans 2005 recommendations are based on the preponderance of scientific evidence for lowering risk of chronic disease and promoting health. It is important to remember that these are integrated messages that should be implemented as a whole. Taken together, they encourage most Americans to eat fewer calories, be more active, and make wiser food choices.

The Reports key recommendations are grouped under nine inter related focus areas.

1. Adequate Nutrients within Calorie Needs
2. Weight Management
3. Physical Activity
4. Food Groups to Encourage
5. Fats
6. Carbohydrates
7. Sodium and Potassium
8. Alcoholic Beverages
9. Food Safety

A basic premise of the Dietary Guidelines is that food guidance should recommend diets that will provide all the nutrients needed for growth and health. To this end, food guidance should encourage individuals to achieve the most recent nutrient intake recommendations of the Institute of Medicine, referred to collectively as the Dietary Reference Intakes (DRIs).

An additional premise of the Dietary Guidelines is that the nutrients consumed should come primarily from foods. Foods contain not only the vitamins and minerals that are often found in supplements, but also hundreds of naturally occurring substances, including carotenoids, flavonoids, isoflavones, and protease inhibitors that may protect against chronic health conditions. There are instances when fortified foods may be advantageous. These include providing additional sources of certain nutrients that might otherwise be present only in low amounts in some food sources, providing nutrients in highly bioavailable forms, and where the fortification addresses a documented public health need.

While the Dietary Guidelines was developed for healthy Americans 2 years of age and older, where appropriate, the needs of specific population groups have been addressed.

Based on dietary intake data or evidence of public health problems, Dietary Guidelines for Americans 2005 summarizes that the intake levels of the following nutrients may be of concern for:

• Adults: calcium, potassium, fiber, magnesium, and vitamins A (as carotenoids), C, and E,
• Children and adolescents: calcium, potassium, fiber, magnesium, and vitamin E,
• Specific population groups: vitamin B12, iron, folic acid, and vitamins E and D.

Additionally the Dietary Guidelines for Americans 2005 made the following key recommendations for the specific population group of Children and Adolescents. Children should:³¹

• Consume whole-grain products often; at least half the grains should be whole grains.
• Children 2 to 8 years should consume 2 cups per day of fat-free or low-fat milk or equivalent milk products
• Children 9 years of age and older should consume 3 cups per day of fat-free or low-fat milk or equivalent milk products.

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.³²

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:³³

• 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.³⁴

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:³⁵

• 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.³⁶

The Dietary Guidelines for Americans 2005 key recommendations for specific population groups regarding weight loss are:³⁷

• 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:³⁸

• 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.

Servings Sizes

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 2005 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.³⁹

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.

Some recommended sources of calcium are:*

• Yogurt#
• Milk**#
• Natural cheeses such as Mozzarella, Cheddar, Swiss, and Parmesan#
• Soy-based beverage with added calcium
• Tofu, if made with calcium sulfate (read the ingredient list)
• Breakfast cereal with added calcium
• Canned fish with soft bones such as salmon, sardines†
• Fruit juice with added calcium
• Pudding made with milk#
• Soup made with milk#
• Dark-green leafy vegetables such as collards, turnip greens

Fat

The Dietary Guidelines for Americans 2005 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 2005 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.

The Dietary Guidelines for Americans 2005 emphasizes that 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 2005 key recommendations for specific population groups are:⁴⁰

• 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 following chart shows the estimated amounts of calories needed to maintain energy balance for various gender and age groups at three different levels of physical activity. The estimates are rounded to the nearest 200 calories.

Food Safety

The Dietary Guidelines for Americans 2005 key recommendation for specific population groups regarding food safety are:

• Infants and young children, pregnant women, older adults, and those who are immunocompromised. Do not eat or drink raw (unpasteurized) milk or any products made from unpasteurized milk, raw or partially cooked eggs or foods containing raw eggs, raw or undercooked meat and poultry, raw or undercooked fish or shellfish, unpasteurized juices, and raw sprouts.

Summary

Obesity frequently becomes a lifelong issue. The reason most obese adolescents gain back their lost pounds is that after they have reached their goal, they go back to their old habits of eating and exercising. An obese adolescent must therefore learn to eat and enjoy healthy foods in moderate amounts and to exercise regularly to maintain the desired weight. Parents of an obese child can improve their child's self esteem by emphasizing the child's strengths and positive qualities rather than just focusing on their weight problem.

The future of our nation is our young people. The obesity epidemic in children must be combated through a comprehensive, multi-faceted, multi-level approach. There are no quick fixes when it comes to losing weight and it is only through proper diet and exercise that good health can be maintained and improved.

The CDC recommends that all segments of society - family, government, organizations, industries, schools, and healthcare providers - must become involved in designing and implementing changes to reduce the prevalence of overweight and obesity.

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