Read an Excerpt
Our Overweight ChildrenWHAT PARENTS, SCHOOLS AND COMMUNITIES CAN DO TO CONTROL THE FATNESS EPIDEMIC
By Sharron Dalton
The University of California PressCopyright © 2004 Regents of the University of California
All right reserved.
Chapter OneNURTURING HEALTHY AND ACTIVE LIFESTYLES
ONE QUESTION FROM TWENTY YEARS AGO haunts my memory. I was leading a workshop with health professionals representing a variety of agencies that served parents and children. The topic was childhood obesity. Most of the participants were mothers and grandmothers; about half were African American and Hispanic; the majority worked in government and health-care programs, as administrators or directly with patients; many were in minority or low-income communities. The objectives of the workshop were ones this book shares: to understand obesity's causes and to explore and suggest appropriate, effective remedies.
I showed a video clip from a documentary dramatization of four- and five-year-old children being asked to look at drawings of children and pick one they would like to have as a friend. The drawings showed children with various physical difficulties; one was obese. Invariably the obese child came last. Most participants nodded in recognition, and some told of similar experiences among children they knew. Two or three spoke passionately about the injustice of fatdiscrimination.
I had just summarized prevalence data and was about to discuss the health risks of childhood obesity when an impatient voice demanded, "I want to hear something new." An articulate Hispanic director of a small center for immigrant children from the Dominican Republic worked with children she described as chronically overweight. She began by stressing the severity of the problem and said she felt frustrated and burned-out. She knew what caused the problem-"They eat big fast-food meals every day and drink lots of whole milk as they're glued to TV"-but she had no remedies, no way to help these families stop or treat the children's unhealthy weight gain. Then she spoke the challenge that could only come from intense experience and rings in my ears as I recall it now:
Professor, I know how to identify fat children, to talk to them so they don't feel miserable. I know why these kids are fat and getting fatter. What I don't know and am increasingly impatient to hear is what the experts claim is most likely to work when we try to help parents with fat kids. I've read the literature that says families should eat together. But after telling people that for seven years, I have no idea of how they can do it. The same is true for exercise; parents are rarely good role models for this, and even if they are themselves slim and active, that can't compete with a peer group watching some wild video together and munching chips. Parental role modeling? Health workers like us handing out advice? Please, Professor Dalton, tell us something that actually brings results!
Shouts of "Amen!" and loud applause rang out when she finished.
The response I gave at that workshop at least began well. I agreed with the group that as health professionals we needed to find ways to help and also encourage people to help themselves. I listed the kinds of support experts propose to prevent and treat childhood obesity. I pointed out that some of the advice draws on research data but has very little evidence about what is effective, especially in the long term, and that there are many more questions about what works than there are answers. We then pooled ideas and experiences of how to treat childhood obesity.
Yet my response was surely inadequate. The problem is challenging and her question stands: what really works to motivate and help children who are at risk or already struggling with obesity?
This book's final part takes up and tries to answer her question. The general approaches and practical advice I advocate on the following pages may appear relatively simple and basic. They are, because they must be. Imagine asking parents, many of whom have struggled with being overweight their entire lives, to do all of the following: decipher nutritional labels, count their children's calories, measure their portion sizes, and keep track of their protein-carbohydrate-fat ratio at every meal-and while they do so, to avoid sugar, soda, fried foods, and certain kinds of fats but not others; to exercise daily, cook healthy meals from scratch, and fix family members' schedules so everyone can eat dinner together; and to banish the TV. Many parents would throw up their hands in frustration and give up trying to lead healthier lives. In fact many do give up, and thus the epidemic grows. Therefore, to help the families hardest hit by this epidemic-those on the lower end of the socioeconomic scale, who face multiple challenges in their lives that compete for their resources and attention-we must deemphasize the complexity of the issue and put forth feasible and realistic remedies everyone can adopt for the long term.
Hence we focus on understandable, general guidelines with practical strategies to implement them, and then leverage a handful of manageable and moderate steps to make a significant impact on children's health.
For example, we know that children need to become more physically active. Parents on a budget and pressed for time may think they cannot get their children to exercise more because of the cost and time needed for organized recreational classes such as gymnastics or karate. My message to everyone is that physical activity does not have to be complicated, costly, or very time consuming. Parents should try instead to turn off the television an extra hour each day and use the time to encourage their children to engage in more active pastimes, which can be as simple as playing tag or dancing to pop music. As one report noted, "Opportunities for spontaneous play may be the only requirement that young children need to increase their physical activity. Reducing the amount of time that children are allowed to watch television is one strategy that offers children opportunities for activity, and it is likely to alter requests for advertised foods as well."
Similarly, we know that many children eat too much and therefore need to reduce their calorie intake. Parents need to know that this does not have to involve embarking on a strict or trendy diet. Moderate steps to change eating behavior-such as sharing family meals, offering children a variety of healthy foods, and respecting children's choices not to eat a specified amount-will go a long way toward reducing young children's access to and consumption of foods that are fattening.
These are not novel approaches. In fact, they were the norm a generation ago, when there were fewer alternatives. Now a return to basics seems essential. Why? Because we have few other strategies, because none of these interventions is likely to have adverse effects, and because all of these actions will improve the quality of family life. But the basics are simpler in theory than in practice, because they require that parents and children manage their many choices for eating food and spending time. It is not enough to educate ourselves on what we should do; we need strategies for how to do it.
To that end, this chapter offers strategies to help lay a foundation for healthy eating and activity in practice, not just in theory. The focus here is on the prevention of excessive weight gain. We examine ways that all parents can exert the appropriate degree of control in feeding and raising children so children are more likely to self-regulate their eating and spend their time in a healthy manner. Building on that foundation, I present my top recommendations for lifelong healthy weight management and discuss ways to raise resilient children equipped to withstand the fattening forces beyond their home. Chapter 7 targets treatment, conveying specific nutritional guidance and evaluating popular weight-loss programs, as well as examining the risks, among children, associated with weight loss (namely, disordered eating and unhealthy body image). Because the line between "prevention" and "treatment" is fuzzy, strategies for prevention are also sound suggestions for children who already are too heavy and need to slow their rate of weight gain.
PREVENTION: THE FIRST-AND BEST-COURSE OF TREATMENT
Obesity is the most prevalent but also the most preventable health affliction of children today. If prevention were easy, we would not need treatment for childhood obesity. With one out of four children already overweight or at risk of becoming overweight, we clearly need both prevention and treatment strategies, now, at all levels-for individual children, families, communities, and schools, as well as in health care and other social and institutional networks.
So often, the predictable response to obesity is to put resources toward treatment with little attention to prevention. Consider, for instance, a recent addition to the already frighteningly long list of medical complications obese children often experience, a liver disease called NASH, for non-alcoholic steatohepatitis. How dreadful: obese fourteen-year-olds are getting a liver disease similar to one induced by excess alcohol in adults! One of the first questions that spring to mind is, which medication will treat the malfunctioning liver that results from obesity? The drug industry is working to develop a medication to improve liver function in obese children with NASH. Of course, we all worry about serious afflictions like this among children and hope a medical remedy can be found. But developing medical treatments for obesity is a Band-Aid solution. Prevention, not medicine, represents the best hope for protecting our children from potentially life-threatening afflictions related to obesity and a lifetime of clinical treatment that may have side effects-at overwhelming cost to families and our health-care system.
Parents hold the keys to prevention; they determine what young children eat and their choice of physical activities. Choices of older children and adolescents, including what they eat and how they spend time, draw on a larger group of their parents, teachers, and peers. And to some degree, all age groups respond to the lure of products on TV, at the supermarket, and at the mall. Nonetheless, given the importance of early childhood in patterns for eating habits and the primary influence that parents exert, we must look to parents as the starting point for any strategies against childhood obesity. Recall the key risk factors for obesity, outlined in chapter 3: parental obesity; unhealthful eating patterns and eating styles; low physical activity; excessive television and computer time; low socioeconomic status. Individual parents may not be able to curb their own obesity and raise their socioeconomic status, but they can take steps to minimize the other risk factors on that list.
Obesity is not a disease that eludes prevention or recovery. Scientists know that mice, caged in an experimental laboratory, can be made fat on a typical American diet. They can be made thin if food is reduced and made thin much faster if placed on a treadmill. But we are dealing with children, not mice. We cannot force them onto a treadmill and feed them a carefully controlled diet day in and day out, because their finicky nature and their yearning for autonomy will lead them to rebel against such heavy-handed measures to control their activity and eating. Moreover, we raise them in an environment full of choices-a fully stocked refrigerator, a multichannel television set-and those choices multiply once they reach school age, gain independence, and venture out on their own. We believe in choice and want plenty of food easily available, but how can we help our children learn to choose food in moderation and gain adequate physical activity? Becoming an authoritative parent is one path toward this goal-a path any parent can and should take.
BECOME AN AUTHORITATIVE PARENT
Authoritative parenting, as outlined in chapter 4, is the middle ground between permissive and authoritarian styles. Whereas permissive parents might have abundant high-calorie snacks always and easily available or authoritarian parents might strictly forbid eating them at all, authoritative parents have a firm but flexible structure for when and how to enjoy a variety of foods as snacks. Authoritative parents neither give their children free rein nor hold them in too tightly; rather, they set parameters for their children that help them learn how to set limits on their own and how to exercise self-control. Parents who set limits to keep their children's world a manageable size are doing the right thing, because they are showing them how to structure the many choices available for eating and spending time. Raising children to manage their lifestyle choices is one form of insurance against obesity in an environment that can be so contrary to a healthy lifestyle.
Limit setting becomes an obstacle course for some children if caregivers first encourage them to eat more than they want or need during early childhood (age one to three), and then restrict foods later (age three to five). For example, a parent might serve second helpings to a two-year-old-even though the child did not indicate she wanted more-and then tell her, "You have to make all that chicken and rice disappear from your plate before you can leave the table." Later, when the child reaches age four, the same parent might say, "No more second helpings or dessert for you after all the snacking you did this afternoon." In one study, overweight and normal-weight eight- to twelve-year-old children ate at significantly different paces only when the mother was in the room too. In her presence, overweight children ate faster and with larger bites than the normal-weight children and speeded up eating near the end of the meal. One interpretation is that as toddlers, they learned this response to reinforcement to "clean the plate." Or it could be a learned coping response to stress among older overweight children. "If I hurry, no one will notice how much I ate." Either way, the study shows that parental presence and practices affect overweight children's eating behavior more than of children with normal weight. If parents are too pushy and then too restrictive, children get mixed messages.
Key to being an authoritative parent is finding an appropriate level of control and structure in feeding a child, with the goal being to nurture the child's self-control as well as a liking for a variety of foods. Children need limits and guidance, but the evidence is quite strong that strictly prohibiting foods usually backfires when kids later on have a free choice of foods, and restricting their food likely leads to overeating. Even so, being overly permissive and serving unlimited portions of whatever older children desire leads to overeating too. Young children generally stop eating when they feel full, while older children-above age six or so-will eat beyond fullness when consistently exposed to large portions. Their bodies will expand by getting fatter and so will their stomach capacity as they override their satiety signals until eating too much becomes habitual.
Because parents' own eating behavior is as important as their style of parenting around food, children often get confusing messages. For example, a mother who is "always on a diet" and tells her child to "clean your plate" demonstrates food restriction while simultaneously sending the message to "eat more." Modifying parent behavior is a good place to begin in preventing a child from experiencing difficulty in noticing fullness or from overeating "forbidden foods" when they get a chance.
Rather than force a child to eat specified amounts of certain foods or, at the other extreme, adopt a laissez-faire approach at mealtimes, parents should aim for moderation. To find that golden mean, I strongly recommend a method developed by Ellyn Satter and described in her book Child of Mine: Feeding with Love and Good Sense. Out of all the texts, her research and its application are outstanding and remain valid today. Satter encourages parents to observe what she calls "the division of responsibility" in child feeding:
Parents are responsible for the what, when, and where of feeding.
Excerpted from Our Overweight Children by Sharron Dalton Copyright © 2004 by Regents of the University of California. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.