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According to the United States Department of Health
and Human Services, poor diet and physical inactivity are the leading
contributors to obesity and premature death. Yet both of these factors
are in our control if they are identified early and behavior is
changed. Unfortunately, in recent years, our children have come
to suffer from this societal trend. The number of obese children
has more than tripled in the last 30 years. Along with opposing
availability of soft drinks and other less nutritious snacks from
public schools, the American Academy of Pediatrics has recently
concluded that “overweight or obesity is the most common medical
condition of childhood”.
It is critical that we respond to this preventable health problem
in our children. Town & Country Pediatrics has put together
some information to guide you as a concerned parent of a child with
a weight issue. We are also providing an eating
diary/exercise log. (This document will open in a new window.
Print it out for your use.)
Childhood Nutrition
Frequently asked questions about childhood nutrition.
1. Why are children becoming so overweight?
2. My child may be holding on to “baby fat”,
this really won’t be a problem or will it?
3. What are the long term risks to childhood obesity?
4. What can I do to help my child with a weight issue?
5. Where do I begin to help my child?
6. What if my overweight child is a teenager?
7. Why is physical activity important and how much?
8. What can my child’s primary health care provider
do for us?
9. Do children have an intrinsic ability to control
their food intake?
10. What should I do if I think my child has an eating
disorder?
11. Is the Food Guide Pyramid applicable to young children?
12. What are the nutrient needs of children ( a short
nutrition lesson)?
13. What can I do to prevent my child from becoming
overweight?
Links and Consultation
1. Why are children becoming so overweight?
Children become overweight because they take in too many calories
compared to the amount of calories their bodies use from normal
daily activity. In most cases, the answer is simple. Children eat
more and move less. Families are busy! With working parents, children
are eating more fast food and school-prepared meals, drinking more
soft drinks and choosing convenience foods over healthier option.
In 1977, children ate only about 1 in 10 meals from fast food restaurants,
but by 1996 that ratio was 1 in 3 meals. Unfortunately, fast food
meals usually contain twice the calories of a meal cooked at home.
Children, when left to make their own choices, will opt for sugary,
calorie-dense foods for snacks and meals.
Television and the increased reliance on computers and the use
of computerized video games has increased the rate of obesity with
our young children. The average American child watches television
nearly 21 hours per week. Another study found that children under
6 devote 2 hours per day to TV, videos, and computers. Television
viewing is thought to promote weight gain not only because it displaces
physical activity but also because children are prone to passively
consuming excessive amounts of caloric foods while watching. During
television viewing, children in the United States are exposed to
about 10 commercials per hour most for fast food, soft drinks, sweets
and sugar-sweetened breakfast cereals.
Children who live in large cities, like Chicago, have an increased
incidence of obesity because there is less access to physical activity.
Urban-dwelling children have fewer safe places to play, ride bikes,
walk, and less physical education in schools than children in other
geographical areas. Children in these areas arguably spend more
time watching TV, playing video games, and exploring the internet-
maybe with a snack in their hand.
The best way to encourage a healthy lifestyle for a child is to
change their environment (food choices, food availability) and increase
their activity. This is an effort for the entire family- children
cannot do this by themselves. As parents, the responsibility lies
with you to encourage children to make healthier food choices and
to encourage physical activity.
If you feel that your child’s activity and dietary choices
are not contributing to the weight issue, it is important that you
contact your child’s primary health care provider. Though
uncommon in children, there are some physiologic reasons for obesity
that may need to be explored.
2. My child may be holding on to “baby fat”,
this really won’t be a problem or will it?
It may be a problem. When we picture a “healthy baby”,
we often times imagine a chubby-cheeked cherubic infant. However,
if a preschool aged child still is “holding on to the baby
fat”, it may be a sign of a weight issue. Being overweight
as a young child can be predictive of obesity as an adult. In fact,
1 out of 4 children overweight at 6 years of age will be overweight
as adults, while 3 out of 4 children overweight at 12 years will
be overweight as adults.
3. What are the long term risks to childhood obesity?
There are many long term risks-too many to mention in this one
section-obviously prevention is key. Children who are overweight
are at risk for many health problems including high blood pressure,
non-insulin dependent Type II diabetes, sleep apnea, and orthopedic
problems. Children who are overweight have an increased heart rate
and cardiac output than their non-obese peers-over time this places
undue stress on the heart at a very early age.
In addition, the psychological stress of being overweight can lower
a child’s self-esteem, contribute to depression and poor peer
socialization. Some children even develop eating disorders as a
result of these psychological stressors. Reviews of the literature
find that quality of life of obese children can be heavily compromised.
An overweight child’s quality of life has been compared to
the life of a child who has been diagnosed with and being treated
for a life threatening illness. Four-eleven year-old children describe
obese peers as “ugly” “lazy” and “stupid”
compared to their average weight peers.
Research has shown that obese children and adolescents are 4 times
more likely to experience problems with school assignments and will
miss an average of 4.2 days of school during the month.
4. What can I do to help my child with a weight issue?
One of the most important things you can do for your overweight
child is to develop a healthy lifestyle yourself. Childhood obesity
is often a family lifestyle issue, no one particular person is to
blame. Children model their behavior after their parents and caretakers.
When your child sees you care for your body by eating the right
foods and exercising, he or she is more likely to do the same. Children
are not responsible for purchasing groceries for a household. If
you buy healthy foods for home then your child will eat them when
junk food is not available to them (at least while they are under
your roof!).
5. Where do I begin to help my child?
First of all, children should not be placed on restrictive diets,
but learn to make healthy food choices whether at home or at school.
These changes take time, and resistance to any change is a normal
part of the process. Often, parents and children need the support
of their primary health care provider, a dietician, and possibly,
a psychologist when making a lifestyle change. Changes take time
and patience. An overweight child should not be singled out in the
family. For lifestyle changes for one child to be successful, everyone
in the family must change and be supportive to one another. Tactics
that focus on small but permanent changes in eating may be more
accepted than drastic changes.
There are some immediate changes that can be made without too much
resistance from children. They include:
- Avoid bringing sugary, empty calorie foods (junk foods) into
the house.
- Offer healthy meals on a schedule (try to plan ahead if you
can)-do not skip meals especially breakfast.
- Change to skim milk as long as the child is older than age 3.
- No pop or soft drinks-limit juices to 100% juice 4-6 oz/day
- Limit restaurant dining/take-out.
- Allow no more than 1 hour of TV/computer/video game on school
days and on weekends or holidays- 2 hours.
- Find opportunities for children to be active- if not in the
home then outside the home- sports, active games, etc.
- Take care of yourself- children learn by example.
- Food should not be used for non-nutritive purposes such as comfort
or reward.
- Limit setting for children are important- guide the child without
arguments if possible- remember you are the parent.
It is important to reward behavior changes rather than weight changes.
Reinforcement for effective behavioral change should be a small
reward or an outing with a parent or trip to the zoo etc- it should
never be food.
6. What if my overweight child is a teenager?
Studies show that 80% of overweight teenagers will become overweight
adults. Teenagers are different in many ways developmentally than
children. They want independence and are angry if they sense that
adults are attempting to control them. The approach to helping teenagers
is different than the approach to helping children with a weight
problem. They must be committed to the task of losing or maintaining
their own weight. Avoid nagging arguments about different foods
or exercise with your teenager- they will “tune you out”.
Fortunately, there are some factors in your control. For instance,
do not buy junk food- these foods are tempting. Also consider a
reward- some positive reinforcement for effort and/or success. Maintain
a “united front” – both parents need to agree
on food choices and general attitudes on weight management (again
role modeling will help). In addition, try to limit restaurant eating
with your teenager.
It may be difficult to encourage physical activity with your overweight
teen. A teen may feel very overwhelmed for a number of reasons the
least of which may be attributed to peer ridicule. A few words of
wisdom may help. Encourage them not to judge themselves- take each
day one at a time- if they did not exercise yesterday it is not
a new trend- just exercise today and hopefully tomorrow. Don’t
call it exercise- call it movement and activity. Not all physical
activity requires going to a gym class and taking a shower afterwards.
Teenagers enjoy company -a buddy can help- if other friends and
family members will join in- it is a lot more fun. The same exercise
every day can be boring- tell them to make a list of physical activities,
it doesn’t have to be much (play tag with the dog) and try
to do something different each week. Don’t burn out- it is
important to start with less activity working up to more activity-
best not to strain muscles too much too fast.
Unfortunately, with ongoing independence, teenagers have access
to food that may not be the best choice. In this situation, teens
are sometimes amenable to contract setting- try contracts with clearly
defined goals that are attainable, and a reward for success- not
food.
7. Why is physical activity important and how much?
Physical inactivity is associated with decreased life expectancy
and increased risk of cardiovascular disease. As a parent it is
important to encourage children to participate in some sort of physical
activity or exercise- and what better way than through modeling-
everyone can join in as a family. Unfortunately, inactive children
are likely to become inactive adults.
The American Heart Association recommends all children age 2 and
older should participate in at least 30 minutes of medium intensity
exercise every day. Children should also engage in at least 30 minutes
of vigorous physical activity 3-4 days each week for cardiovascular
fitness. Winter city living may present some challenges to these
recommendations- shoot for two 15-minute intervals or three 10 minute
intervals. Promoting exercise in children may be as easy as shutting
off the television and taking away the computer video games.
8. What can my child’s primary health care
provider do for us?
Preventing weight gain is most important- your child’s primary
health care provider will emphasize preventing weight gain above
what is appropriate for expected increase in height. This is called
prevention of greater weight gain velocity. For some children this
may mean little or no weight gain during a certain period. Your
primary health care provider should be the first one to consult
if you feel your child has a weight issue. A thorough family history,
a complete physical exam, and laboratory tests may be needed. Your
child’s growth curves will be plotted and a Body Mass Index
(BMI) will be measured. BMI= weight (kg)/ height (m) squared. BMI
is the standard obesity assessment in adults and its use in children
provides a consistent measure across the age groups. BMI correlates
with measures of body fatness in children and adolescents. The correlation
coefficient ranges from 0.39 -0.90. The National Center for Health
Statistics recommends that children and adolescents with BMI greater
than or equal to the 95th percentile for age and sex should undergo
a more in-depth medical assessment. Children who fall at or above
the 95th percentile identify children who are at risk for persistence
of obesity into adulthood. A comprehensive medical assessment includes
but is not limited to weight history, precipitating events (stressors,
etc.), family history of obesity/cardiovascular disease, patient
patterns of diet/physical activity, and family diet/physical activity
patterns. A child/teen’s eating behavior may best be assessed
by discussing the types and amounts of foods that are consumed (in
and out of a parent’s presence). Where is most of the eating
occurring? How is the eating occurring (emotionally charged situations,
binging, etc.). Laboratory testing will also be employed for further
assessment. The National Cholesterol Education Program Expert Panel
on Blood Cholesterol Levels in Children and Adolescents recommends
that health care providers consider screening all obese children
over two years of age for elevated cholesterol levels.
A child and parent’s motivation and attitude are critical
to the success of making changing in diet and activity. Parents
and children must know that obesity is a chronic problem requiring
long-term treatment. Depending on your child’s age, treatment
of obesity can be more challenging.
A child should never be placed “on a diet” unless your
health care provider recommends weight loss instead of weight maintenance.
He/she will monitor your progress carefully, possibly with the help
of a pediatric nutritional specialist. A reasonable weight loss
goal may be 1-4 pounds per month, with a dietary prescription specifying
the total number of calories per day and recommended percentage
of calories from fat, protein, and carbohydrates. A food diary should
be kept with the type and quantity of food eaten, where it was eaten,
the time of day, etc. An example of a food diary may be found here
in Figure A. Physical activity should also be increased according
to the child’s fitness level with the ultimate goal of 20-30
minutes per day (this is in addition to any school activity). Initial
exercise recommendations should be small and exercise levels should
be increased slowly to avoid possible discouragement. See Figure
B for a personal exercise log. Your health care provider or nutritionist
may suggest behavior modification of eating habits and recommend
attitude changes, reinforcements and rewards. Stimulus control includes
limiting the amount of fattening foods in the house, eating all
meals at the table and at designated times, and serving food only
once before putting it away (no seconds). Parents should not encourage
the child to eat if he/she doesn’t want to and the child should
not be forced to finish the entire meal. Other examples of modifying
eating behavior include taking smaller bites, chewing food longer,
putting the fork down between bites and leaving some food on the
plate. In addition the level of family involvement will be assessed-
family activity levels, television viewing patterns and motivation
to achieve nutritional goals for themselves and the child. The family
is the child’s major social learning environment and should
be included in the treatment plan.
9. Do children have an intrinsic ability to control
their food intake?
Yes! There is a multitude of research that suggests that even infants
have the ability to control their food intake when offered. This
research also applies to the characteristically finicky preschooler.
There is a great deal of variability in this area and parents have
the ability from day one to influence whether children can listen
to their internal hunger/satiety cues. While it may be difficult
in some instances, parents need to respect and listen to a child’s
innate ability to control his/her intake. For example, at 4:00 p.m.
a child tells his mother, “I’m hungry” and the
mother says “we are eating in 1 hour, you can’t have
anything right now”, this tells the child that the way they
feel is not as important as the clock. Instead of ignoring the child’s
cue, offer one of the components of the dinner or an appetizer course
you are serving with dinner with anyway- such as vegetables. This
reinforces the child’s hunger cue and also allows the mother
to continue making dinner.
Parents may find it difficult to strike a balance between letting
children do it their way and imposing a little control to ensure
adequate nutrition and variety. Does a child know he needs some
more green vegetables in his diet? No. But he does know how much
he wants to eat and when. The parental responsibility then takes
on a role for provision of a variety of foods children need and
then allow them to obey their internal cues and eat as much or as
little as they want. And allowance should be made to mix in a little
sweet now and then. Arguably, some children like to graze all day.
It may be important to set some limits on what foods a parent may
offer and when. A child states that he is hungry- offer something
like a piece of fruit or vegetable or raisins, if he or she doesn’t
want what the parent is offering, say “well that is all that
we have now” and explain that it may be some time before the
next meal. A hungry child will eat and the bored child will just
skip it and wait until the meal is served.
It is important to mention that it takes the brain 20 minutes to
process body information that food is being taken in- imagine how
long it takes to know that a child’s tummy is full!
10. What should I do if I think my child has an eating disorder?
A diagnosis of eating disorder may be considered if there is obsessive
thinking/worrying about body and weight or if there is a long history
of dieting and unhealthy weight practices or emotion related eating
(starving, binging, vomiting food, etc.). If you are concerned about
your child in this capacity, make an appointment immediately with
your health care provider.
11. Is the Food Guide Pyramid applicable to young children?
A great resource regarding the US Food Guide Pyramid can be found
at www.mypyramid.gov
12. What are the nutrient needs of children ( a
short nutrition lesson)?
The Recommended Dietary Allowances (RDA) provide information concerning
children’s nutrient needs. A number of recommendations indicate
what constitutes a healthful diet for children. The Dietary Guidelines
for Americans provide advice about food choices that promote health
and prevent disease among healthy Americans 2 years and older. The
Guidelines advise Americans to eat a varied diet with plenty of
grain products, vegetables, and fruits, while moderating their intakes
of fat, saturated fat, cholesterol, sugars, salt and sodium, and
alcoholic beverages. In addition, the Guidelines also caution that
fat should not be restricted for children younger than age 2, and
that major efforts to change a child’s diet should be accompanied
by monitoring of growth at regular intervals by a health care provider.
Children between the ages of 2 and 5 should gradually begin to initiate
a diet so that it contains no more than 30 percent of calories from
fat and that children older than age 5 continue with those same
guidelines.
Nutrients in foods include macronutrients like carbohydrates, proteins
and fats and micronutrients like vitamins and minerals. Intake of
all types is necessary for growth and development. Carbohydrates
are the primary energy source that fuels your muscles and brain.
The majority of the daily food intake (50-55%) should come from
foods that provide carbohydrates. You should give preference to
complex carbohydrates such as wheat products, other grains such
as rye, beans and root vegetables. Because complex carbohydrates
are larger molecules than simple carbohydrates (such as fruits,
some dairy products and honey), they are slower sources of energy.
But energy can be generated from them quickly. The body stores very
small amounts of excess energy as carbohydrates. The liver stores
some as glycogen which is a complex carbohydrate that the body can
easily and rapidly convert into energy if needed. Muscles can also
store glycogen which can be used for intense exercise. Proteins
such as meat, nuts, and eggs are units of amino acids strung together
in complex formations- they are the major component of many body
structures used for building and repairing body tissues. Because
proteins are complex molecules, the body takes longer to break them
down and digest them. They are a much slower and longer-lasting
source of energy than carbohydrates. There are twenty amino acids.
The body creates some of them from components within the body, but
it cannot make 9 of the amino acids called the essential amino acids.
They must be consumed as food for the body to utilize them. Fats
such as sweets and oils are complex molecules composed of fatty
acids and glycerol. Fats are the slowest source of energy but the
most energy-efficient form of food. Each gram of fat supplies the
body with about 9 calories more than twice that supplied by proteins
(4 calories) and carbohydrates (4 calories). Because fats are such
an efficient form of energy, the body stores any excess energy as
fat. The body deposits excess fat in the abdomen and under the skin
to use when it needs more energy. The body also stores excess fat
in blood vessels and within organs where it may block blood flow
and cause damage. Micronutrients are vitamins and some minerals-
almost all of these need to be eaten in the form of food and thus
are essential nutrients. Vitamins are water soluble (C, B) or fat
soluble (A, D, E, K). Vitamins help support metabolism and regulate
the immune system. Some minerals are considered macronutrients because
they must be taken in in fairly large quantities such as calcium,
chloride, magnesium, phosphorus, potassium, and sodium. The trace
minerals are considered micronutrients because the body only needs
small amounts of them- these are copper, fluoride, iodine, iron,
selenium, and zinc. Please consult the United States Department
of Agriculture’s web site for viewing a food guide pyramid
designed implicitly for children. Armed with knowledge of nutrients
and application of the food guide pyramid, meals may be better planned
with nutrition in mind.
13. What can I do to prevent my child from becoming overweight?
The most important factor to consider is that children model their
parents. To encourage proper nutrition with your child- it is paramount
that you set a good example yourself. No one ever said having children
would be easy- a balanced diet and regular exercise is important
to teach children a healthy lifestyle. One way to start is to serve
a variety of foods and let your children see you eating them. Children
need to taste a new food 8-10 times before they’ll learn to
accept it. In addition, exercise is extremely important- active
parents inspire active children. Technically speaking however, recent
research has suggested that there are critical periods for preventing
the process of excessive weight gain. One of these periods is infancy.
The American Academy of Pediatrics strongly recommends breast milk
as the sole source of nutrition until 6 months of age. Studies have
shown that feeding breast milk among other benefits, can lower the
risk of obesity in later years. As your infant develops into a toddler
and beyond, it is important to offer nutritious snacks such as vegetables
and fruits, low fat dairy foods and whole grains. Foods such as
yogurt, unsweetened cereals, oatmeal, cheese, pretzels, dried fruit,
and whole grain crackers and breads are some suggestions. Another
critical period is the time in your child’s development when
the Body Mass Index (BMI) is at its lowest. This point of maximal
leanness or minimal BMI has been called the adiposity rebound (AR).
It has been demonstrated that this time is crucial for developing
or avoiding overweight. Five to six years of age is average for
this normal stage of development. This age may “run in families”
and may be difficult to modify, but this point of minimal BMI may
also be influenced by environmental factors that may be changed
or modified. These environmental factors include increasing exercise,
decreasing sedentary activities (computer/television time), and
providing healthy food choices. At five and six years of age, children
are also notoriously picky eaters- parents may start to employ tactics
such as “if you eat this…then you will get this dessert”.
This strategy may teach the child at this critical developmental
period to tell his/her body to follow external rather than internal
cues for hunger or “feeling full”. Food should never
be used as a reward for any behavior. It is important to empower
the child to establish his/her own personal ability to regulate
food intake and to stop when he/she is full. The teenage years are
also a critical period for prevention of later obesity. Overweight
teens usually become overweight adults. The literature also suggests
that teens who engage in high risk behaviors such as smoking, alcohol
and early sexual experimentation may also be at greater risk of
poor dietary and exercise habits.
Links:
For consultation:
- Gary Sigman, MD- Evanston Northwestern Health Care Adolescent/Young
Adult Medicine
(847) 663-8352
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