Obesity Report Cards: Worthy Intervention or Needless Interference?

So you open up your 10 year old daughter's report card. It shows good grades in her academic subjects, her behavior is fine, and she gets along well with other kids. And, oh, by the way, "her body mass index (BMI)

is greater than 90% of children her age."
Translation: she's overweight and "eventually could be at risk for serious medical problems which you need to discuss ASAP with her pediatric provider."

This "obesity report card" is becoming more popular as the schools look to intervene on the epidemic of childhood obesity. How would you feel if this happened to you? Would you be angry or grateful for the heads-up?

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For many years, I co-taught a class in the Boston University School of Public Health in which we discussed "the child, the family, and the state." We pondered when the state should trump parental rights and forcibly intervene to assure a child's health and well–being.

I think most of us would agree (although you never know around here) on certain circumstances when this is the case: to protect maltreated kids, to enforce certain mandatory safety measures (like car seats and seat belts), to order the environmental clean-up of unsafe water and toxins (like lead) and other hazards to their safety, to enforce child labor laws...

Fair enough. But what about the child who is significantly overweight? Is that a risk warranting intervention by the state (i.e., the school system) or is there already too much on their plate just teaching the 3 R's?

And if you vote yes, is an "obesity report card" a wise way to go?

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So far, everyone seems to agree that childhood obesity is an important and legitimate issue for pediatric providers to try to tackle. I've addressed this many times (e.g., see my other posts) and no one has objected that it's none of my business.

But what should be the role, if any, of our schools? I first learned about the "obesity report card" in a New York Times article, entitled, "As obesity fight hits schools, many fear a note from the school."* The article went on to note the irony of many of the participating schools having cut out gym and offering students cafeteria meals that look like this:

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Parents' response to this unasked-for information was mixed. Some were shocked and outraged, and felt that their child's weight was not the school's business. Others appreciated the reminder and, given the seriousness of the problem, felt it might make them and others more likely to do something about it.

My view? Not a great idea.

Let me be clear: I do believe schools can and should play a role in combating childhood obesity. It's a national pediatric scourge and a legitimate major worry. But schools need to play to their strengths, that is by educating kids on sound nutritional principles and the value of exercise, by infusing the peer culture at school with the values of a healthy diet and exercise, by teaching a culture of tolerance and sensitivity towards those who are overweight, by offering healthy, low animal fat meals, and by banning soda and junk food vending machines from the premises.

But not by badgering and, by extension, condemning parents about what they almost certainly already know about their child's overweight (hey, that's my job!), which is a complex, hard-to-solve problem for any family (and pediatrician), and rarely one with simple solutions, like informing parents and advising them to simply do the right thing.

The state usually isn't great (in fact, more often than not, it stinks) at changing family behaviors and values - especially with a challenge so culturally ingrained and emotionally charged as feeding relationships and values within a family. The obesity report card is a case where I think their efforts are likely to prove useless, and could even do some harm with its laudable, but heavy-handed attempt to solve a tough problem.

Your thoughts?

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*Article cited
As Obesity Fight Hits Cafeteria, Many Fear a Note From School

Related Topics

• Snacks for Kids on the Go
• WebMD Video: Healthy Weight for Kids

Technorati Tags: childhood obesity, New York Times, nutrition, diet

Overweight toddler, overweight teen? Dr. P's 8 steps to a healthier family

"So, Billy" I said to my cherubic six year old patient, in for a routine check-up. "I see your birthday is next week. What are you hoping to get as a present?"

He looked at me with shiny, hopeful eyes. "A Barcalounger," was his breathtaking response.

I think it this was at this exact moment (which happened about a decade ago) that I finally realized how profoundly the landscape for kids and obesity had changed. Now, of course, you can't avoid reading about it. And for good reason: the number of overweight kids is skyrocketing and worthy of every parent's attention.

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I've blogged a lot about this subject before:

• Obese toddlers who can't fit into a normal car seat
• Overfeeding as a sign of love
• The advantages of a low animal fat diet
• Soda and juice intake contributing to obesity

Now comes new research* showing that overweight toddlers have a 40-50% chance of becoming overweight 12 year olds - which is a 6 times more likely risk compared to their thinner toddler pals.

This is still complicated. Genetics, as always, plays a significant role in both directions: some toddlers and children (and adults whom, of course, we all hate) can eat non-stop and never become overweight. Others might just as well apply the ice cream directly to their cute and ever-growing pot bellies and thunder thighs. It's those kids, this study suggests, for whom more care to prevent them from becoming overweight would be worthwhile.

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What does this mean for you parents? As usual, it's hard to find the right balance.

Certainly, putting a toddler on a diet is almost never a good idea. And obsessing about overweight so much that it becomes a constant battle and source of worry also misses the boat. After all, a childhood without any ice cream is unthinkable, I don't care what you weigh.

But, as parents, there are measures you can take for the entire family that will benefit everyone's health and, at the same time, serve to keep the excess weight off those of your kids who are susceptible to becoming overweight.

Dr P's 8 steps to a healthier family:

1. Cut down on animal fat (skimmed or 1% fat milk and dairy products after the age of 3; use unsaturated oils; more broiled and baked, fewer fried foods).
2. Smaller portions of foods for all.
3. Don't use food as a reward for good behavior.
4. Minimal junk food.
5. Nutritious, low-calorie snacks like fruits and veggies. If they don't like it, tough. They can wait until the next meal to eat. They won't starve.
6. Remembering that health, not food = love.
7. Minimal juice and soda. Water as the beverage of choice!
8. Plenty of opportunities for exercise (it's estimated that kids need at least 90 minutes / day of moderate exercise to stay fit).

Your goal is not a skinny toddler, just one who is not overweight and who, hopefully, will learn excellent eating preferences and exercise habits that will benefit him/her in the teen years to come.

I'd welcome hearing about nutritional and exercise strategies that have worked with your kids.

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*Article cited:
"Identifying risk for obesity in early childhood"
Pediatrics, September 2006, e594-601

Related Topics: WebMD Video: Keeping Kids Active, Motivating the Overweight Child, Extreme Obesity in Tots Linked to Low IQ

Technorati Tags: obese toddlers, diet, exercise, family nutrition, parenting

Health, Not Food = Love

"Eat! Eat! How often do I see you?"
Dr. P's grandma

"Food is love"
As a child I would visit my immigrant grandma and, just for me, she would have made her famous oily fried chicken and her lethal-dose mayonnaise potato salad and, of course, a generous supply of her might-as-well-just-directly-paste-them-onto-your-butt creamy cookies, "just like in the old country ".

Yum! I can still taste them to this day - a glorious childhood memory. And if I didn't ask for seconds (at least) or eat a dozen cookies, she was all over it, insisting, "Eat! Eat! How often do I see you?"

The truth is: food really is love.

A baby learns to associate the divine smell and taste of milk with warmth and cuddling and soft skin and gentle words and human interaction and nurturing and cozy love - a multi-sensory emotional feast.

Plus, our brains are wired to love the taste of food (alas, the more fat and the more sugar the better!). How can we not then appreciate and love the vehicles who generously put it in our eager mouths? What better way to promote child-parent attachment? (When I collaborated with Dr. Spock and he recommended a milk-free diet, I was horrified by the thought of a childhood without ice cream!) As George Bernard Shaw, the Irish dramatist, wrote, "There is no love sincerer than the love of food."

So too does food = love for parents. A woman's first official act and most solemn responsibility as a new parent is to nourish her infant. A "fat baby is a healthy baby" has long been a universal truism. A fat child is a sign of high social status in many cultures. We may not have nearly as much control of our kids' lives as we might want, but we can feed them 3 squares a day. It's an easy, "can't miss" way to demonstrate our love.

So where's the problem?
Am I just another killjoy puritan (defined by the American humorist H.L. Mencken as a person with "the desperate fear that someone, somewhere might be having a good time.")?

As I have written in a few previous blogs, the epidemic of childhood obesity - showing up at earlier and earlier ages - is a major 21st century health concern. And I've been honest in sharing my frustration as a pediatrician in successfully helping my patients and families deal with their overweight child.

Recently I've been thinking a lot about why I can't seem to get anywhere with this problem, why parents' eyes lid over as they politely tune out my lecture about decreasing animal fat and junk food, why they show up in my office a few months later with a hangdog look on their face and a child with 5 new pounds of body weight.

For some reason, this old saw kept echoing in my brain: food is love, food is love. Remember that controversial and excruciating case a few years ago of the young, morbidly obese child who was taken away from her Latino parents on the grounds that continuing to feed her was a form of 'child abuse'?

For many parents of overweight children, asking them to cut down on calories, to deprive their child of one of his/her favorite things in life, to diminish this pure message of parental love and regard -- is simply asking too much, especially to prevent health concerns (like diabetes, heart disease, hypertension) that are not likely to show up for decades.

How can I do a better job helping overweight kids and their families?

Some initial thoughts:

• Try to help parents change their awareness to "health, not food = love." Even if your child won't really appreciate it until much later, as a parent you can best show your love by having a healthy child. (And then launch into my usual healthy diet and exercise mantra.)
• "Feed everyone much smaller portions." In 1760, a portly Benjamin Franklin wrote, "In general, mankind, since the improvement of cookery, eats twice as much as nature requires." Why are the French (and their kids) skinny? It's not a mystery. Portion size. (Plus they don't snack between meals). A typical French meal is perhaps 1/2 the size of a stick-to-your-ribs supersized American meal. They even feed their babies less milk to avoid excessive baby fat (which I'm not recommending until more is known).
• Admittedly, this is a tough sell in our culture, but "smaller portions have their advantages." There is not much deprivation in the type and wonderful variety and tastes of food you can eat. A nice small dessert is allowed. I'm convinced we have been programmed in childood not to be satisfied unless we are very full, instead of just a little hungry (or at least not stuffed) when we leave the table.
• "There are other ways to show your love." In the shorter time it takes to eat smaller meals, you can be with your child, do fun things together, interact in great ways. Yes, I'm talking about some extra quantity of quality time together as a way to supplant food as the best way to express your love.

As you can see, this is a work-in-progess I'm sharing with you. I'm getting desperate to figure out ways to inspire parents to follow sound nutritional advice. And I'm hoping to use my Blog to improve and refine my ability to improve outcomes for overweight kids and their families.

Help me (and my patients) out here, team. I'd love to hear from you! Tips, thoughts, suggestions...?

Related Topics: Quiz: How Healthy Is Your Diet?, Fast Food Choices

Technorati Tags: parenting, childhood obesity, diet and nutrition, fast food, portion control

Too fat for a car seat?

Dr. P's Pediatric Journal Club

The study
The authors looked at growth data on U.S. children ages 1-6 years from the 1999-2000 National Health and Nutrition Examination Survey (N-HANES) and compared it to the maximal weight recommended for child safety seats.

What the study found

• About 283,000 children in the U.S. are at risk for not finding an appropriate child safety seat due to obesity.
• Of these, the majority (183,000) were 3 year olds weighing more than 40 pounds. (This works out to about one in every twenty 3 year olds.)
• There were only 4 oversized models of car seats made to accommodate wide load toddlers and these all cost about $250.

Dr. P comments
As we say in the trade: oy vay!

I've blogged and harangued you before about the stunning increase in childhood obesity, about the long-term risks of diabetes, heart disease, and hypertension, about the wisdom of feeding your family a low animal fat, minimal junk food diet, and about the need for everyone to get sufficient exercise.

But most of my warnings about obesity were of consequences some time off in the future. These clever authors have identified a risk that can affect a child's safety today, especially in those families who can't afford or don't think it's neccessary or don't think to buy a specially enlarged, expensive car seat for their big guy or gal.

Improper restraint in the car is especially worrisome because:

• More than 1.5 million kids/year are involved in a car accident.
• Car accidents are the leading cause of death in children. For example, they account for almost 1/3 of all preschooler deaths.
• Car seats reduce the risk of a fatal injury by 71% in infants using rear-facing seats and 54% in toddlers secured in forward facing seats. [Editorial comment: Keep your infants in a rear-facing car seat as long as you can, preferably until they are married!]
• Forward facing seats are not meant to be used by a child weighing more than 40 pounds. Why not? As explained in http://www.carseat.org/: "Children who are under 4 years old or who are very active may not stay put without a 5 point harness system that holds them in place. Booster seats do not work well for those children because vehicle shoulder belts do not prevent them from leaning forward or placing the shoulder belt behind the back or under the arm."
  

The only good news in these stunning numbers is that car seat manufacturers will likely seize the opportunity and begin to make more "hefty" models to meet the demand of an ever-widening population of preschoolers. Then, if good old American capitalism and competition do their magic, prices will drop and more families will be able to afford them.

For more information on the proper use of car seats, go to http://www.aap.org/family/carseatguide.htm

Related Topics: 10 Ways to Raise Food-Smart Kids, Calculate your Child's BMI

Technorati Tags: toddlers, car seats, childhood obesity, obesity

Help for your overweight teen

Dr. P's Pediatric Journal Club

The study

This was a randomized, controlled trial (the most scientifically valid kind) lasting 6 months. Teens, age 13-18 years, were randomly divided into two groups:

1. Got zero-calorie beverages (water, diet soda) delivered to their home + a magnet on the refrigerator stating "Think before you drink" + phone reminders not to drink sugar-sweetened beverages.
2. A "control" group that did not change their dietary intake.
   

What the study found

• The zero-calorie beverage group decreased their sugar-sweetened beverage intake by 82%.
• The heavier a teen was initially, the greater effect this had on weight gain.
• The heaviest teens gained one pound / month less, compared to the control group.

What the study suggests
A simple intervention of eliminating sugar-sweetened beverages is an effective weight-loss strategy for overweight teens.

Dr. P comments
A true confession from Dr. P: my track record is pretty bad in helping overweight kids lose weight.

I'm not alone: many of my colleagues (and parents and kids) share my frustration. The sad fact is that there is no great treatment for overweight kids yet. This is especially frustrating given the serious epidemic of obesity in kids and its very real medical consequences.

There are many reasons for our dismal track record:

• Only 1/3 of parents actually recognize that their child is overweight.
• Many families aren't aware of how fattening the food is that they are feeding their kids.
• "Food is love". Who even wants to deprive their kids of fried chicken?
• Schools are not providing low fat, healthy meals and serve sugary beverages.
• As many of us sadly know, controlling one's appetite is easier said than done.
• Many diets are complicated and seem overwhelming to even attempt.
• Even if motivated, restraint is rarely a teenager's strong point.
  

This study gives me hope. It suggests that by simply decreasing intake of sugary drinks and juices (which have no real nutritional value and do not suppress appetite), we can knock off about a pound/month of weight gain. Not a huge amount, but it's a start. It's simple and, unlike most diet measures, not much of a deprivation.

One problem is that teens are brainwashed to think many sugar-sweetened beverages are healthy, energy boosting and, worst of all, cool. I suspect it may take a national campaign (such as has successfully occurred with smoking) to turn those perceptions around, to make drinking water the really cool thing to do.

Putting this information together with the advice of my blogs of 12/26/05 and 12/12/05, here is Dr. P's simple-as-can-be nutritional advice for overweight teens and their families:

• Increase exercise.
• Serve a low animal fat, low junk food diet most of the time.
• Zero-calorie beverages only.
  

Yes, yes, I know that these simple recommendations are not the magic answer for your teen's overweight. But don't let the perfect be the enemy of the good. You can implement these measures: they are relatively simple and pain-free, and they are proven effective. All and all, they'd make make a good start.

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A Dr. P "unidentified flying fact" to give you pause:

Drinking a single 12-ounce can of a sugar-sweetened soft drink / day --> one pound of extra weight gain every 3-4 weeks.

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A caveat from Dr. P:

So far, little is known about whether artifical sweetener intake by young children could lead to long-term adverse effects of some kind. Consult your pediatric provider should you want to use them in your pre-teen kids.

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Article cited:
"Effects of Decreasing Sugar-Sweetened Beverage Consumption on Body Weight in Adolescents: A Randomized, Controlled Pilot Study". Ebbeling C, et al. Pediatrics. March, 2006.

Related Topics: A Healthy Diet for Teen Girls Only, WebMD Video: Keeping Your Kids Active

Technorati Tags: teenagers, obesity, diet, fitness

Your teenager's physical fitness

Dr. P's Pediatric Journal Club

"Prevalence and Cardiovascular Disease Correlates of Low Cardiorespiratory Fitness in Adolescents and Adults " Carnethon M, Greenland P.

Journal of the American Medical Association. Dec. 21, 2005

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The study

3,110 adolescents (age 12-19 years) underwent an 8 minute treadmill test that increased their heart rates and consumption of oxygen. After this cardiovacular 'stress test', they were classified as either "fit" or "unfit", based on national normal values.

What the study found

Low fitness was identified in 1/3 of adolescents (= 7.5 million US adolescents). The prevalence was similar in females and males. Non-Hispanic blacks and Mexican Americans were less fit than non-Hispanic whites. Poor fitness was associated with higher blood pressures, with being fatter, with higher cholesterol and lower "good fat" (HDL) levels.

What this study suggests

From an early age, many American children are out of shape, placing them at greater risk for heart disease, diabetes, even some types of cancer as adults.

Dr. P comments

Everyone knows about the epidemic of obesity in children - 1 out 6 American children is seriously overweight. Now we find that fully 1 out of 3 adolescents can't pass a simple treadmill test of cardiovascular fitness!

Obesity is no mystery: too many calories in + not enough exercise. In my 12/12/05 Blog, I discussed the benefits of a low animal fat diet for your family, but that is only half the story.

Other studies have shown that, even by age 3 years, children are not as active as they used to be. You can guess why: TVs, computers, escalators, cars, and parents/adults who may not be the best role models --> CPITs (couch potatoes in training).

Make physical fitness a family value. Be sure there are opportunities to exercise every day, take walks or ride bikes together, climb the stairs instead of the escalator, sign your kids up for their sport of choice, talk to them about the benefits of exercise (health, fun, feeling good, competence at sports).

It's not that often we can see trouble so clearly down the road and actually have effective ways to prevent it. If your family serves high calorie foods with lots of animal fat + have kids who don't get much exercise... well, Dr. P really doesn't need to badger you: you know what you need to do. Now is as good a time as any to get started.

Related Topics: Fitness Impacts Heart Disease Risk, Fit Mom, Fit Kids

Tags: teens,diet,exercise,fitness