When Terry Malin's* first baby, Ashley,* was delivered eight years ago, the hospital weighed her at 8 pounds, 8 ounces. She had a boundless appetite. As a toddler, she'd pop cheese slices straight from the fridge. She loved the burgers and pizza her mom, an office manager in St. Louis, brought home on nights when she felt too tired to cook. By age 2, Ashley fit into clothes designed for a 4-year-old. Malin was concerned, even though several of the pediatricians in the medical group to which she belonged shrugged her off.
When Ashley turned 4, a new doctor in the group examined her. He took one look at Ashley—42 inches, 71 pounds—and exclaimed, "This child's obese!"
Malin did some research, and she found a local pediatric-obesity clinic at Cardinal Glennon Children's Hospital. There was a six-month waiting list. "Clearly, we weren't the only ones with a problem," she says.
Far from it.
* Name has been changed.
Carol Lynn Mithers's last article for Parenting was "The Literacy Crisis," in the September issue.
A Dangerous Tide
The Malin family is on the front lines of one of America's most pervasive health crises. The number of children who are overweight has more than tripled in a generation. In 1960 only 4 percent of children ages 6 to 11 were seriously overweight, according to federal statistics. By 1980 it was 7 percent. It jumped again by the early '90s, and by 1999 the figure was 13 percent.
The problem is hitting younger kids too. One out of every ten preschoolers—ten percent—is now overweight, notes Christine Williams, M.D., professor of clinical pediatrics at Columbia University.
These children face higher-than-normal odds of becoming obese adults—a risk that increases the heavier they are and the longer they're overweight. Heavy adults face a higher risk of heart disease, diabetes, high blood pressure, high cholesterol levels, and some kinds of cancer. Through chronic disease, obesity kills about 300,000 Americans a year.
Some health problems start before adulthood. Overweight children tend to reach puberty sooner; for girls, this means longer lifetime exposure to estrogen, which may mean a greater risk of breast cancer when they are adults. Type II diabetes—the obesity-related disease once dubbed "adult-onset"—is now rising rapidly in teens, preteens, and even younger children, according to the latest American Diabetes Association figures.
Overweight kids also show early evidence of physical changes that eventually may lead to heart disease, says Gerald Berenson, M.D., director of the Tulane Center for Cardiovascular Health, in New Orleans. "A ten-year-old who is about fifteen pounds over his or her ideal weight will have higher blood pressure and cholesterol levels and lower levels of HDL, the 'good' cholesterol," says Dr. Berenson. Even in kids from 2 to 5, being overweight is linked to elevated blood pressure, according to Dr. Williams.
The health problems overweight children face aren't just physical. Overweight kids ages 6 to 11 may "become targets of early and systematic discrimination," reported William Dietz, M.D., director of nutrition at the Centers for Disease Control and Prevention, in the journal Pediatrics three years ago. Dr. Dietz says, "The peers of the most overweight children associate obesity with negative characteristics, such as laziness and sloppiness."
That's something the mothers of overweight kids know only too well. "When she was four, my daughter came home from daycare crying because 'Ryan told me I was fat,'" recalls Jean Heimroth, a bank officer in Riverhead, NY.
"I was overweight as a child and teen, and I had no self-esteem throughout high school," says Kelly Brigante of Santee, CA, whose daughter, 3, is "off the charts" at 55 pounds. "Now, when Emily says, 'I have a perfect body!' I answer, 'Yes, you do!' But my heart breaks. I know what's ahead for her."
The United States of Obesity
The new data confirm that obesity rates in children are rising across gender lines, across the country, and across age, race, and educational levels.
"Part of the frustration for those of us who work in the field is 'Why don't Americans perceive this problem?'" says James Hill, Ph.D., director of the Center for Human Nutrition at the University of Colorado Health Sciences Center, in Denver. "If these trends continue, within a few generations every American will be overweight."
Could it really happen? Not literally, acknowledges Hill: Some people will always be genetically predisposed to thinness, others to being overweight. Brigante's husband, mother, grandmother, and great-grandmother, for example, have all struggled with their weight.
But it isn't our genes that have suddenly changed in a single generation. What has changed is our society. It has become easier than ever to overeat, at any time, whether you're sitting in a stroller or toddling through the mall. Snacks not only are packaged in bigger sizes but also pack more calories per serving than 20 years ago, find University of North Carolina researchers. More and more time-stressed families eat out—for as many as 40 percent of meals—and restaurant portion sizes have grown as well. "Supersizing" fast-food meals adds hundreds of calories.
School-age children have more than doubled their daily consumption of soft drinks and fruit beverages in the past two decades. Even pure fruit juice has come under scrutiny: The newest guidelines from the American Academy of Pediatrics (AAP) urge parents of 1- to 6-year-olds to limit daily consumption of fruit juice to four to six ounces. Tooth decay is one concern, but so is the contribution to the childhood-obesity epidemic.
For slightly older kids, soft drinks can be a weight trap. In a recent two-year study of middle school children, those who had at least one sugar-sweetened soft drink a day—soda, sweetened fruit drinks, lemonade, sweetened ice tea—were most likely to be overweight. "Soft drinks should be allowed only as a rare treat," advises David Ludwig, M.D., director of the Obesity Program at Children's Hospital in Boston. "They do not provide optimal nutrition for children, and our research shows that they can contribute to the development of obesity." Be flexible, he says. "Allow a cup or so only on special occasions so that your child understands that soft drinks are a once-in-a-while treat."
Another problem: In a drive to cut dietary fat, many parents "have simply substituted refined carbohydrates and concentrated sugars," notes Dr. Ludwig. "When that means a child's diet is full of white bread and sugared breakfast cereal, that's not doing him any favors." And kids don't have to be visibly gorging themselves to develop a problem. If a child consumes an extra 100 calories a day—a small bag of fries or a can of soda—he can put on 10 extra pounds in a year.
The Inactive Child
At the same time that american children are eating more, they're also—like American adults—leading increasingly sedentary lives. Only seven states even require elementary schools to have certified physical education instructors, and some schools have canceled recess to allow more time for academics.
A bigger problem: Instead of spending time in physical play, many kids amuse themselves with television, video games and computers. Says James Hill, "There's a mismatch between our physiology and our environment."
The AAP cites Nielsen ratings showing that children ages 2 to 5 watch about 25 hours of TV per week. And the more time a child watches TV, studies find, the more likely he'll be overweight—not only because he's less active during those hours but also because he's snacking and watching commercials for high-fat, high-sugar foods. "When children watch a lot of television, they tend to eat more," says Dr. Dietz.
Because of their increasingly busy lives, it's hard for parents to find the time to engage their children in active play—and tempting to use TV as a babysitter. "Ashley was a very sedentary child," says Terry Malin. "She could watch TV for hours. And I admit that I let her, because after a long day of work, it gave me a break to get things done around the house."
What to Do Now
Slowing the rise in obesity will require a massive social effort to promote healthier foods (more fruits and veggies, fewer high-calorie snacks) and more activity in schools and communities—as big as the campaigns that followed the Surgeon General's warnings on smoking back in 1964. Until then, what can you do if you are a parent of a toddler, preschooler, or kindergartner? Plenty, it turns out, whether you are trying to prevent future weight problems for your child or nip an emerging one in the bud.
Experts point to these years—when kids readily listen to their parents and imitate their behavior—as the perfect time to prevent childhood obesity and head off the obsession with slenderness that can lead to eating disorders.
"I don't focus on diets or body size—I talk to my daughter about listening to herself," says Jean Heimroth, who read extensively about weight loss and put her family on a Weight Watchers diet. "When she says she's hungry, I ask, 'Is your tummy really grumbling? Or are you just bored?' And we don't talk about 'fat' or 'thin.' The truth is, Julia will not be petite, and I want her to appreciate that people come in all shapes. But I tell her that she needs to eat healthy to make her body strong."
Heimroth is trying to help her daughter hold her weight steady as she "grows into it." It's an approach pediatricians endorse for children, who in fact rarely need to lose weight as they grow. If this plan proves ineffective after two years, Dr. Dietz suggests consulting your pediatrician about a stricter program.
Whether you're trying to prevent excess weight gain or help an already overweight child, here's how to start:
Control what to eat, but let your child control how much. Many experts consider this a key strategy, popularized by author, dietitian, and therapist Ellyn Satter, Ph.D.: Parents control the specific foods served for snacks and family meals—making sure the meals are healthy and balanced—but not the child's portions. "Letting go of control can be scary for parents who are concerned that their child is becoming overweight," says Caroline Cederquist, M.D., a family doctor in Naples, FL, who specializes in obesity. "But if you tell a child how much to eat, he'll never learn what it feels like to have his body tell him, 'I'm full. That's enough.'"
Engage all caregivers. Your efforts won't help if they're undermined by babysitters who serve extra hot dogs and huge bowls of ice cream. Talk to the people who take care of your child during the day to be sure you understand how they're feeding her—and make concrete, gentle suggestions for alternatives. Enlist their help in your shared goal of helping your child get healthier.
Watch portions. "Offer kid-size servings," says obesity expert Sarah Barlow, M.D., assistant professor of pediatrics at St. Louis University School of Medicine. "And don't order your child to clean his plate!"
Reward without food. Make sure your children receive praise and attention rather than french fries or sweets.
Be vigilant in restaurants. Set limits, such as permitting a hamburger but not the fries, and plan to share entrees. For beverages, ask for milk, OJ, or water.
Offer little sweets. It's fine to give your child a candy treat, says Dr. Cederquist, but offer a single-serving package. "That way, she can eat her portion as quickly or as slowly as she pleases, but she knows that when it's gone, there's no option of seconds or thirds."
Practice what you preach. "Don't drink soda and tell your child he can only have low-fat milk," says Dr. Cederquist.
Cut down on juice. "Six ounces a day will give a child the vitamin C he or she needs," says American Dietetics Association spokesperson Bettye Nowlin. Substitute water or milk—regular until age 2, low- or nonfat thereafter.
Limit TV. To limit inactivity and snacking, keep an eye on total tube time—including video games. The AAP recommends no more than one to two hours of quality programming each day for kids over age 2 (and none for younger ones) and that you don't put a TV in a child's bedroom.
Let kids move. Infants, toddlers, and preschoolers are naturally active, but they need an environment that encourages them to move. "Don't force or direct it," Dr. Dietz cautions. "Build physical exercise into their daily routine." School-age children "should have thirty to sixty minutes of physical activity—some of it vigorous—on all or most days of the week," says Judith Young, Ph.D., executive director of the National Association for Sport and Physical Education. This requires real commitment from parents and schools.
Find a place. Look for an after-school program that features gym activities or a YMCA that offers swimming lessons, dance classes, nature hikes or yoga.
The Road Back
"We now limit Ashley to two hours of TV a day on weekends and only one hour on weekdays," says Malin. Ashley's father goes to pick her up at childcare one mile from their house, and the two walk home together. "Twice a week, I do a low-impact aerobics tape with her. And I try to include a walk with her every day, even if it means I have to sneak one in. I say, 'I want to pick up our photos from the store, but I can't find my car keys. Let's just walk,'" she says.
Just as excess pounds can creep up, small changes in daily life—even such old standbys as taking the stairs instead of the elevator—can produce results.
Heimroth now puts on music rather than the television while fixing dinner, does workout tapes with her daughter, and learned how to cook low-fat meals. She reports that Julia hasn't put on a single pound in six months—and she herself has lost 40.
After some early resistance—including tantrums when extra portions were denied—Ashley Malin lost five pounds in a year (and grew four inches) and, to her mother's delight, recently refused the potato chips she was offered while at a friend's house. "It's an ongoing struggle, and we have our bad days," says Terry Malin, "but all in all, I'm very proud of her. She still does her walks and workout tapes; she started a dance and tumbling class in the fall. She has more energy. So do we. We eat less, we don't get fast food anymore, and the exercise is toning us up too. Ashley's a different child than she was a year ago—and we're a different family."